Clinical outcomes and financial estimates for women attending the largest private midwifery service in Australia compared to national data: a retrospective cohort study.

BACKGROUND AND PROBLEM: Multiple barriers to national scale-out of private midwifery practice in Australia exist. AIM: To describe and compare maternal infant health outcomes of the largest private midwifery service in Australia with the national core maternity indicators and estimate the financial impact on collaborating public hospitals. METHODS: A retrospective cohort of 2747 maternal health records from 2014 to 2022 were compared to national indicators. Financial calculations estimated the impact on hospitals. FINDINGS: Compared to national data, women cared by private midwives were significantly: more likely to be 25-34 years and primiparous; less likely to be Indigenous, have diabetes, hypertension or multiple births. At birth, 5% required discussion with specialists, 25% required consultation and 39% were referred; 86% women had their primary midwife at birth; 12.5% birthed at home and 14.5% at a birth centre. Compared to national data, primiparous women had fewer inductions (22.9% vs 45.8%), caesarean sections (22.6% vs 32.1%), instrumental vaginal births (17.0% vs 25.7%), episiotomies (9.5% vs 23.9%) and more birthed vaginally after caesarean section (75.9% vs 11.9%). Significantly less babies were born with a birthweight <2750 g (0.5% vs 1.2%) and 83.7% babies were exclusively breastfed at six weeks. Collaborating hospitals would receive less DRG funding compared to public patients, require less intrapartum midwifery staff and receive a net benefit, even when bed fees were waived. CONCLUSION: Women attending My Midwives had significantly lower intervention rates when compared to national indicators although maternal characteristics could be contributing. Multidisciplinary care was evident. Financial modelling shows positive impacts for hospitals.

A pre-post implementation study of a care bundle to reduce perineal trauma in unassisted births conducted by midwives.

PROBLEM: The perineal-bundle is a complex intervention widely implemented in Australian maternity care facilities. BACKGROUND: Most bundle components have limited or conflicting evidence and the implementation required many midwives to change their usual practice for preventing perineal trauma. AIM: To measure the effect of perineal bundle implementation on perineal injury for women having unassisted births with midwives. METHODS: A retrospective pre-post implementation study design to determine rates of second degree, severe perineal trauma, and episiotomy. Women who had an unassisted, singleton, cephalic vaginal birth at term between two time periods: January 2011 - November 2017 and August 2018 - August 2020 with a midwife or midwifery student accoucheur. We conducted logistic regression on the primary outcomes to control for confounding variables. FINDINGS: data from 20,155 births (pre-implementation) and 6273 (post-implementation) were analysed. After implementation, no significant difference in likelihood of severe perineal trauma was demonstrated (aOR 0.86, 95% CI 0.71-1.04, p = 0.124). Nulliparous women were more likely to receive an episiotomy (aOR 1.49 95% CI 1.31-1.70 p < 0.001) and multiparous women to suffer a second degree tear (aOR 1.18 95% CI 1.09-1.27 p < 0.001). DISCUSSION: This study adds to the growing body of literature which suggests a number of bundle components are ineffective, and some potentially harmful. Why, and how, the bundle was introduced at scale without a research framework to test efficacy and safety is a key concern. CONCLUSION: Suitably designed trials should be undertaken on all proposed individual or grouped perineal protection strategies prior to broad adoption.

"It's all about cultural understanding": A reflexive thematic analysis of women's experiences at a dedicated refugee midwifery group practice service.

BACKGROUND: Inequitable maternity care provision in high-income countries contributes to ongoing poor outcomes for women of refugee backgrounds. To address barriers to quality maternity care and improve health equity, a co-designed maternity service incorporating community-based group antenatal care, onsite social worker and interpreters, continuity of midwifery carer through a caseload design with 24/7 phone access was implemented for women of refugee background. OBJECTIVE: To explore and describe women's experiences and perceptions of care from a dedicated Refugee Midwifery Group Practice service. DESIGN: Qualitative exploratory descriptive study using focus group discussions and interpreters. SETTING: The study was conducted at a community-based Refugee Midwifery Group Practice service in a tertiary maternity hospital in Brisbane, Australia. METHODS: We conducted three focus group discussions (June - December 2020) with 16 women, born in six different countries, in three language groups: Sudanese Arabic, Somali, and English. We used reflexive thematic analysis to interpret women's perspectives and generate informed meanings of experiences of care. RESULTS: We generated four themes 1) accessibility of care, 2) women feeling accepted, 3) value of relationality, and 4), service expansion and promotion. Results demonstrate positive experiences and acceptability due to easy access, strong woman-midwife relationships, and culturally safe care. CONCLUSION: The service addressed concerns raised in an early evaluation and provides evidence that redesigning maternity services to meet the needs of women with a refugee background speaking multiple languages from many countries is possible and promotes access, use, and satisfaction with care, contributing to improved health equity and perinatal outcomes.

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).

Effect of an Australian community-based caseload midwifery group practice service on maternal and neonatal outcomes for women from a refugee background.

BACKGROUND: Women from a refugee background who resettle in high-income countries experience poorer perinatal outcomes in comparison to women from host countries. There is a paucity of research on how best to improve these outcomes. AIM: To report on the effectiveness of an Australian Refugee Midwifery Group Practice service on perinatal outcomes. METHODS: We used inverse probability of treatment weighting to balance confounders and calculate treatment effect and compare maternal and neonatal outcomes for women from a refugee background who received Refugee Midwifery Group Practice care (n = 625), to those receiving standard care (n = 634) at a large tertiary hospital (1 January 2016-31 December 2019). Prespecified primary outcomes included: proportion of women attending ≥ 5 antenatal visits, preterm birth (<37 weeks), spontaneous onset of labour, epidural analgesia in the first stage of labour, normal birth (term, spontaneous onset, vertex, spontaneous vaginal birth, no epidural, no episiotomy), and exclusively breast-feeding at discharge. FINDINGS: Women who received Refugee Midwifery Group Practice care were more likely to have spontaneous onset of labour (adjusted odds ratio 2·20, 95% CI 1·71-2·82; p < 0·0001), normal birth (1·55, 1·23-1·95; p < 0·0001), and less likely to use epidural analgesia (0·67, 0·50-0·89; p = 0·0067) and have a preterm baby (0·60, 0·36-0·99; p = 0·047). There was no difference between groups in women attending ≥ 5 antenatal visits and exclusive breastfeeding at discharge from hospital. DISCUSSION: A Refugee Midwifery Group Practice is feasible and clinically effective. CONCLUSION: Similar services could potentially improve outcomes for women from a refugee background who resettle in high-income countries.

Midwives experiences of interventions to improve breast expression following preterm birth: A qualitative study.

OBJECTIVE: Preterm birth impacts approximately 10% of women globally. Midwives are often the first point of care after the birth of a preterm infant providing mothers with information and support for breast expression. However, despite guidelines that suggest expression within the first hour of birth, most first expressions occur much later. This study aimed to seek an understanding of midwives' experiences with the first expression for mothers of preterm infants, including the barriers and facilitators that midwives may face. DESIGN: A qualitative design using semi-structured interviews via focus groups. Thematic analysis was used to identify relevant themes and sub-themes. PARTICIPANTS: Participants included midwives providing care to women in preterm labour and birth at a tertiary maternity hospital in Australia (N=12). All participating midwives cared for mothers of preterm infants between 28 and 35 weeks' gestation up to six hours following birth. FINDINGS: Two major themes resulted from the data, including the changing expectations of infant feeding and the responsibility versus expectation to support a woman to express in the first hour of birth with other competing clinical and organisational tasks. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Whilst individual philosophies on the benefits of human milk were positive, expressing in the birth suite was dictated by essential clinical tasks and by the institutions value placed on expressing in the first hour. Clear objectives to undertake expressing within the first hour or within the birth suite stay, need to be included in policy and supported by management and team leaders, to increase early expressing rates.

A Comparison of the Timing of Hand Expressing of Human Milk With Breast Massage to Standard Care for Mothers of Preterm Infants: An Exploratory Pilot Using a Randomized Controlled Design.

BACKGROUND: Globally, 10% of all births are preterm. Access to human milk via manual breast expression is required to reduce the incidence of adverse outcomes related to prematurity. However, there is little evidence to recommend optimum timing to commence breast expression in mothers of preterm infants or the most effective method. RESEARCH AIMS: (1) To test feasibility of recruitment and compliance to the protocol and (2) to determine influence of using hand expressing and breast massage on milk production, engorgement, mastitis, and breastfeeding status at 3 months. METHODS: This study was an exploratory parallel two-group, pilot randomized controlled trial. Mothers of preterm infants at a metropolitan maternity hospital in Queensland Australia (N = 31) were randomized to receive either hand expressing and breast massage within the 1st hr of birth or standard care, hand expressing within 6 hr of birth, to determine the influence on milk production, engorgement, mastitis, and breastfeeding status at 3 months. RESULTS: Feasibility targets were not met; however, valuable learning from this trial uncovered barriers facing midwives in the birth suite to commencing expressing in the 1st hr of birth. There was no difference in occurrence of secondary outcomes, although trends support future study. CONCLUSIONS: Overall, unpredictability of preterm birth influenced our ability to recruit participants. Important directions for future study design would benefit from incorporating expressing times up to 6 hr with a replicable breast massage.

Midwives speaking out on COVID-19: The international confederation of midwives global survey.

BACKGROUND: Maternity services around the world have been disrupted since the outbreak of the COVID-19 pandemic. The International Confederation of Midwives (ICM) representing one hundred and forty-three professional midwifery associations across the world sought to understand the impact of the pandemic on women and midwives. AIM: The aim of this study was to understand the global impact of COVID-19 from the point of view of midwives' associations. METHODS: A descriptive cross-sectional survey using an on-line questionnaire was sent via email to every midwives' association member of ICM. SURVEY INSTRUMENT: The survey was developed and tested by a small global team of midwife researchers and clinicians. It consisted of 106 questions divided into seven discreet sections. Each member association was invited to make one response in either English, French or Spanish. RESULTS: Data were collected between July 2020 and April 2021. All respondents fulfilling the inclusion criteria irrespective of whether they completed all questions in the survey were eligible for analysis. All data collected was anonymous. There were 101 surveys returned from the 143 member associations across the world. Many countries reported being caught unaware of the severity of the infection and in some places, midwives were forced to make their own PPE, or reuse single use PPE. Disruption to maternity services meant women had to change their plans for place of birth; and in many countries maternity facilities were closed to become COVID-19 centres. Half of all respondents stated that women were afraid to give birth in hospitals during the pandemic resulting in increased demand for home birth and community midwifery. Midwifery students were denied access to practical or clinical placements and their registration as midwives has been delayed in many countries. More than 50% of the associations reported that governments did not consult them, and they have little or no say in policy at government levels. These poor outcomes were not exclusive to high-, middle- or low-income countries. CONCLUSIONS: Strong recommendations that stem from this research include the need to include midwifery representation on key government committees and a need to increase the support for planned out of hospital birth. Both these recommendations stand to enhance the effectiveness of midwives in a world that continues to face and may face future catastrophic pandemics.

Is a randomized controlled trial of waterbirth possible? An Australian feasibility study.

BACKGROUND: The safety of waterbirth is contested because of the lack of evidence from randomized trials and conflicting results. This research assessed the feasibility of a prospective study of waterbirth (trial or cohort). METHODS: We conducted a prospective cohort study at an Australian maternity hospital. Eligible women with uncomplicated pregnancies at 36 weeks of gestation were recruited and surveyed about their willingness for randomization. The primary midwife assessed waterbirth eligibility and intention on admission in labor, and onset of second stage. Primary outcomes measured feasibility. Intention-to-treat analysis, and per-protocol analysis, compared clinical outcomes of women and their babies who intended waterbirth and nonwaterbirth at onset of second stage. RESULTS: 1260 participants were recruited; 15% (n = 188) agreed to randomization in a future trial. 550 women were analyzed by intention-to-treat analysis: 351 (waterbirth) and 199 (nonwaterbirth). In per-protocol analysis, 14% (n = 48) were excluded. Women in the waterbirth group were less likely to have amniotomy and more likely to have water immersion and physiological third stage. There were no differences in other measures of maternal morbidity. There were no significant differences between groups for serious neonatal morbidity; four cord avulsions occurred in the waterbirth group with none in the landbirth group. An RCT would need approximately 6000 women to be approached at onset of second stage. CONCLUSIONS: A randomized trial of waterbirth compared with nonwaterbirth, powered to detect a difference in serious neonatal morbidity, is unlikely to be feasible. A powered prospective study with intention-to-treat analysis at onset of second stage is feasible.

A call for action that cannot go to voicemail: Research activism to urgently improve Indigenous perinatal health and wellbeing.

In this call to action, a coalition of Indigenous and non-Indigenous researchers from Australia, Aotearoa New Zealand, United States and Canada argue for the urgent need for adequately funded Indigenous-led solutions to perinatal health inequities for Indigenous families in well-resourced settler-colonial countries. Authors describe examples of successful community-driven programs making a difference and call on all peoples to support and resource Indigenous-led perinatal health services by providing practical actions for individuals and different groups.

Women's unmet needs in early labour: Qualitative analysis of free-text survey responses in the M@NGO trial of caseload midwifery.

OBJECTIVE: to analyse women's experiences of early labour care in caseload midwifery in Australia. DESIGN: this study sits within a multi-site randomised controlled trial of caseload midwifery versus standard care. Participant surveys were conducted at 6-weeks and 6-months after birth. Free-text responses about experiences of care were subject to critical thematic analysis in NVivo 11 software. SETTING: two urban Australian hospitals in different states. PARTICIPANTS: women 18 years and over, with a singleton pregnancy, less than 24 weeks' pregnant, not planning a caesarean section or already booked with a care provider; were eligible to participate in the trial. INTERVENTIONS: participants were randomised to caseload midwifery or standard care for antenatal, labour and birth and postpartum care. MEASUREMENTS AND FINDINGS: The 6-week survey response rate was 58% (n = 1,019). The survey included five open questions about women's experiences of pregnancy, labour and birth, and postnatal care. Nine-hundred and one respondents (88%) provided free text comments which were coded to generate 10 categories. The category of early labour contained data from 84 individual participants (caseload care n = 44; standard care n = 40). Descriptive themes were: (1) needing permission; (2) doing the 'wrong' thing; and (3) being dismissed. Analytic themes were: (1) Seeking: women wanting to be "close to those who know what's going on"; and (2) Shielding: midwives defending resources and normal birth. KEY CONCLUSIONS: Regardless of model of care, early labour care was primarily described in negative terms. This could be attributed to reporting bias, because women who were neutral about early labour care may not comment. Nevertheless, the findings demonstrate a gap in knowledge about early labour care in caseload midwifery models. IMPLICATIONS FOR PRACTICE: Maternity services that offer caseload midwifery are ideally placed to evaluate how early labour home visiting impacts women's experiences of early labour.

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.

Effectiveness of breast massage for the treatment of women with breastfeeding problems: a systematic review.

OBJECTIVES: The aim of this systematic review was to identify the effectiveness of breast massage as a treatment for women with breastfeeding problems. More specifically, the objective was to identify if breast massage as an intervention led to less pain or increased milk supply, or assisted in a reduction or resolution of blocked ducts, breast engorgement and mastitis. INTRODUCTION: Breastfeeding protects babies against many illnesses, and the health benefits for women have been well documented. However, breastfeeding rates steadily drop to approximately 15% by six months, which is the World Health Organization's recommended length of time for exclusive breastfeeding. Breastfeeding problems such as blocked ducts, breast engorgement and mastitis are major complications attributing to the decline in breastfeeding rates. Breast massage may relieve pain and resolve symptoms associated with conditions that contribute to discontinued breastfeeding. INCLUSION CRITERIA: This review considered both experimental and epidemiological study designs and included breastfeeding women of any age, parity or geographical location. The types of interventions considered for inclusion were any type of breast massage that was offered to women for breastfeeding problems. Comparators included the usual care provided to women with breastfeeding problems. Primary outcomes of interest were an increase in breast milk supply, reduction of breast pain, and symptom resolution of blocked ducts, engorgement and mastitis. Secondary outcomes included duration of breastfeeding. METHODS: Studies published from 1980 to 2017 in English and Japanese were considered for inclusion in this review. The databases searched with the majority of results included CINAHL, Cochrane Library, Embase, PubMed, Science Direct, Scopus and Web of Science. Search for unpublished studies included Google Scholar, ClinicalTrials.gov and ProQuest Dissertations and Theses. RESULTS: There were six studies included in this review: three randomized controlled trials and three quasi-experimental studies. There was considerable heterogeneity of study outcome measures, and the use of unvalidated tools in many of the studies led to the inability to pool the results. Furthermore, the heterogeneity of the interventions themselves coupled with small sample sizes for each study greatly decreased generalizability of the outcomes and reduced the overall effectiveness of the interventions. However, all included studies reported a reduction in pain regardless of the breast massage technique used. Overall, varying types of breast massage were helpful in reducing immediate pain and resolving symptoms. CONCLUSIONS: Overall, different types of breast massage were reported as effective in reducing immediate pain for the participants. However, the lack of detailed explanation of the breast massage technique and the extensive training needed to undertake the breast massage decrease the ability to replicate the results. These outcomes may be useful for healthcare professionals caring for women with breastfeeding problems. Future research needs include validating a universal measurement tool for breastfeeding problems and the need for more robust randomized controlled trials, particularly in vulnerable groups such as mothers of preterm infants. Longer follow-up periods are also suggested to establish if breast massage impacts breastfeeding duration.

Is the Birthing Unit Design Spatial Evaluation Tool valid for diverse groups?

BACKGROUND: Awareness of the impact of the built environment on health care outcomes and experiences has led to efforts to redesign birthing environments. The Birth Unit Design Spatial Evaluation Tool was developed to inform such improvements, but it has only been validated with caseload midwives and women birthing in caseload models of care. AIM: To assess the content validity of the tool with four new participant groups: Birth unit midwives, Aboriginal or Torres Strait Islander women; women who had anticipated a vaginal birth after a caesarean; and women from refugee or culturally and linguistically diverse backgrounds. METHODS: Participants completed a Likert-scale survey to rate the relevance of The Birth Unit Design Spatial Evaluation Tool's 69 items. Item-level content validity and Survey-level validity indices were calculated, with the achievement of validity set at >0.78 and >0.9 respectively. RESULTS: Item-level content validity was achieved on 37 items for birth unit midwives (n=10); 35 items for Aboriginal or Torres Strait Islander women (n=6); 33 items for women who had anticipated a vaginal birth after a caesarean (n=6); and 28 items for women from refugee or culturally and linguistically diverse backgrounds (n=20). Survey-level content validity was not demonstrated in any group. CONCLUSION: Birth environment design remains significant to women and midwives, but the Birth Unit Design Spatial Evaluation Tool was not validated for these participant groups. Further research is needed, using innovative methodologies to address the subconscious level on which environment may influence experience and to disentangle the influence of confounding factors.

Knowledge and use of sterile water injections amongst midwives in the United Kingdom: A cross-sectional study.

BACKGROUND: The use of sterile water injections (SWI) for the relief of pain in labour is popular amongst midwives in countries such as Sweden and Australia. Anecdotal reports suggest the procedure is used less commonly in the United Kingdom (UK) and that a number of barriers to introducing the practice may exist. OBJECTIVE: The objective of this study was to explore the awareness and use of SWI amongst midwives in the UK. DESIGN: A cross-sectional study using an internet-based questionnaire. PARTICIPANTS: Midwives with Nursing and Midwifery Council Registration and currently practicing. SETTING: The questionnaire was distributed via the Royal College of Midwives Facebook page and Twitter account. Invitations to participate were also sent to Heads of Midwifery to distribute to staff. FINDINGS: Three hundred and ninety-eight midwives completed the survey. Eighty-two percent of midwives did not use SWI in practice although 69% would consider learning the procedure. There was considerable variation in techniques amongst midwives that did provide SWI. The lack of available practice guidelines and the advice from the National Institute for Health and Care Excellence to not use SWI were cited as the main barriers. KEY CONCLUSIONS: SWI use is uncommon in the UK although midwives are interested in incorporating the procedure into practice. IMPLICATIONS FOR PRACTICE: National guidance on SWI and the lack of information and training is restricting the use of the procedure in practice, despite SWI being widely used in other countries and being effective in the treatment of pain in labour.

Disaster in pregnancy: midwifery continuity positively impacts infant neurodevelopment, QF2011 study.

BACKGROUND: Research shows that continuity of midwifery carer in pregnancy improves maternal and neonatal outcomes. This study examines whether midwifery group practice (MGP) care during pregnancy affects infant neurodevelopment at 6-months of age compared to women receiving standard hospital maternity care (SC) in the context of a natural disaster. METHODS: This prospective cohort study included 115 women who were affected by a sudden-onset flood during pregnancy. They received one of two models of maternity care: MGP or SC. The women's flood-related objective stress, subjective reactions, and cognitive appraisal of the disaster were assessed at recruitment into the study. At 6-months postpartum they completed the Ages and Stages Questionnaire (ASQ-3) on their infants' communication, fine and gross motor, problem solving, and personal-social skills. RESULTS: Greater maternal objective and subjective stress predicted worse infant outcomes. Even when controlling for maternal stress from the flood, infants of mothers who were in the MGP model of maternity care performed better than infants of mothers in SC on two of the five ASQ-3 domains (fine motor and problem solving) at 6-months of age. Furthermore, infants in the SC model were more likely to be identified as at risk for delayed development on these domains than infants in the MGP model of care. CONCLUSIONS: Continuity of midwifery care has positive effects on infant neurodevelopment when mothers experience disaster-related stress in pregnancy, with significantly better outcomes on two developmental domains at 6 months compared to infants whose mothers received standard hospital care.

Comparing Different Partograph Designs for Use in Standard Labor Care: A Pilot Randomized Trial.

Backgound Partographs are used in many labour settings to provide a pictorial overview of a woman's cervical dilation pattern in the first stage of labor and to alert clinicians to slow progress possibly requiring intervention. Recent reviews called for large trials to establish the efficacy of partographs to improve birth outcomes whilst highlighting issues of clinician compliance with use. Previous studies have also reported issues with participant recruitment related to concerns regarding the possibility of a longer labour. Objectives We sought to compare a standard partograph with an action line, to a newly designed partograph with a stepped line, to determine the feasibility of recruitment to a larger clinical trial. Methods A pragmatic, single-blind randomised trial wherein low-risk, nulliparous women in spontaneous labour at term were randomized to an action-line or stepped-line partograph. First stage labour management was guided by the allocated partograph. Primary outcomes included the proportion of eligible women recruited, reasons for failed recruitment and compliance with partograph use. Secondary outcomes included rates of intervention, mode of birth, maternal and neonatal outcomes. Results Of the 384 potentially eligible participants, 38% (149/384) were approached. Of these 77% (116/149) consented, with 85% (99/116) randomized, only nine women approached (6%) declined to participate. A further 9% (14/149) who were consented antenatally were not eligible at onset of labor and 7% (10/149) of women approached in the birth suite but did not meet the inclusion criteria. Compliance with partograph completion was 65% (action) versus 84% (dystocia line). Conclusions for Practice Participant recruitment to a larger randomized controlled trial comparing new labour management guidelines to standard care is feasible. Effective strategies to improve partograph completion compliance would be required to maintain trial fidelity.

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.