Healthy Motherhood

Researchers: A/Prof Angela Taft, Prof Rhonda Small, Ms Leesa Hooker; Cathy Humphreys, Kelsey Hegarty, The University of Melbourne

Partners: Berry Street Family Violence Services, Women’s Health West

Intimate partner violence is prevalent among recent mothers. It can damage a mother's physical and emotional health, compromise her parenting and damage the child's current and future development. The MOVE pragmatic cluster randomised controlled trial examines whether an enhanced intervention model of maternal and child health (MCH) nurses can improve identification and referral of abused mothers and their children.

In this study, we combined a systematic review of guidance for community-based nurses with participatory action research. It involved nurse consultants from four intervention MCH teams. From this we developed consensus clinician guidelines, strategies and resources for an enhanced model of care for MCH clients who experience intimate partner violence. We aimed for a sustainable model of care and drew on the theoretical framework provided by Normalisation Process Theory (May, 2007), which emphasises reinforcement of support for behaviour change at the political, team and individual level. The model included the more formal involvement of family violence services with maternal and child health nurse teams.

The new model was implemented in the four intervention communities for 12 months from April 2010 to April 2011. In September, we conducted an online impact survey with nurses from both arms of the trial (n=114, 71%). We also surveyed 10,000 mothers using the MCH services over eight months, from April to December 2010, from the four intervention and four comparison communities in a postal survey.

The interviews with key stakeholders exploring the impact of the new model on their work have now been completed. Analysis and dissemination of findings is under way.

Researchers: A/Prof Helen McLachlan, Prof Della Forster, Dr Mary-Ann Davey, Ms Michelle Newton; Dr Lisa Gold, Deakin University; Dr Mary Anne Biro, Monash University; Tanya Farrell, Jeremy Oats, Royal Women’s Hospital; Ulla Waldenstrom, Karolinska Institute; Leah Albers, University of New Mexico

Partner: The Royal Women's Hospital

Continuity of carer in the provision of maternity care has been strongly recommended and encouraged in Victoria and throughout Australia. The then Victorian Department of Human Services released a policy document "Future directions for Victoria's maternity services" in June 2004, which endorsed and promoted the expansion of public models of maternity care that offer continuity of carer. Many hospitals responded by introducing caseload midwifery, a one-to-one midwifery model of care in which women are cared for by a primary midwife throughout pregnancy, birth and the early postnatal period. However, this model of care had not been subjected to rigorous evaluation.

"One-to-one midwifery" or caseload care was implemented under trial conditions at the Women's Hospital. We evaluated the effect of caseload midwifery on interventions during childbirth (such as caesarean births, instrumental vaginal births, and induction of labour) compared with standard maternity care. We compared a range of other outcomes such as: perineal trauma; postnatal depression; maternal satisfaction with care; initiation and duration of breastfeeding; costs; health outcomes for mothers and babies; and the impact of the model on midwives and other staff in the organisation. Two thousand three hundred and fourteen women at low risk of medical complications were recruited to the COSMOS trial between September 2007 and June 2010 with the final birth in December 2010. 

This study is the first randomised controlled trial of caseload midwifery care in Australia. The results are urgently needed and will assist policy makers and maternity services in planning for future models of maternity care.

Researcher: Dr Wendy Pollock

Partner: Australian and New Zealand Intensive Care Research Centre

The H1N1 influenza pandemic, which spread rapidly in mid 2009, severely affected pregnant and postpartum women with many requiring admission to an intensive care unit (ICU). A lot of these women needed assistance with breathing, including the use of a breathing tube and breathing machine (ventilator); mechanical ventilation. There has been limited research conducted on the interaction of pregnancy with mechanical ventilation in pregnant women despite a number of major physiological adaptations that normally occur in pregnancy. These normal physiological changes pose significant challenges for the mechanical ventilation of pregnant women and there is little available evidence to guide practice.

The aims of the study are to:

1. Describe the provision of mechanical ventilation to pregnant and postpartum women
2. Compare the provision of mechanical ventilation to pregnant women and a non-pregnant matched control group admitted to ICU with H1N1 influenza
3. Examine the impact of the birth event on the provision of mechanical ventilation for those women who gave birth whilst an inpatient of ICU (n=14)

The case-control study is being conducted in collaboration with the Australian and New Zealand Intensive Care Research Centre and involves the collection of data from 34 intensive care units across Australia and New Zealand. Data are being gathered on daily ventilator settings and associated arterial blood gas results of 44 cases and 44 controls. These data will build on previous data gathered on the same women, relating to the influenza event and management1, and obstetric and neonatal outcome2 and enable comprehensive understanding of the provision of mechanical ventilation to pregnant women including the impact on the pregnancy.

The H1N1 influenza pandemic has afforded a rare opportunity to study the mechanical ventilation of a relatively large study population of pregnant and postpartum women and compare them to a non-pregnant matched control population. This is a landmark study and will make a significant contribution to the knowledge on the provision of ventilation to obstetric patients.

(Funded by the Helen Macpherson Smith Trust)

1. The ANZIC Influenza Investigators. Critical care services and 2009 H1N1 influenza in Australia and New Zealand. N Engl J Med 2009;361:1925-34.
2. The ANZIC Influenza Investigators and Australasian Maternity Outcomes Surveillance System Critical illness due to 2009 A/H1N1 influenza in pregnant and postpartum women: population based cohort study. BMJ 2010;340:c1279. doi:10.1136/bmj.c1279.

Researchers: Dr Mridula Bandyopadhyay, Prof Rhonda Small, Dr Mary-Ann Davey; Prof Jeremy Oats, Ms Amanda Aylward, The Royal Women's Hospital; Ms Catharine McNamara, Dr Deborah Boyce, The Mercy Hospital for Women; Prof Helena Teede, Southern Health

Partners: The Royal Women’s Hospital, The Mercy Hospital for Women, Southern Health

Immigrant women from the Indian sub-continent (South Asia) are more predisposed to developing diabetes in pregnancy – gestational diabetes mellitus (GDM). Our recently concluded pilot study¹ highlighted the significant difficulty these women experienced in self-management of GDM.

GDM affects up to 14-19% of all pregnancies in some populations placing women at risk of adverse pregnancy outcomes^2-3. Although, GDM resolves after childbirth, women with GDM are up to seven times more likely to develop type 2 diabetes within 5-10 years of the index pregnancy^4-5.

This study, informed by our recently concluded pilot study with immigrant South Asian women,1 aimed to gain a better understanding of health care providers’ perspectives about their consultations with South Asian women and also women’s views and experiences of GDM management. 

21 semi-structured interviews were conducted with health care providers involved in GDM treatment and management from three tertiary maternity hospitals in Melbourne; also 23 face-to-face in-depth interviews with South Asian women diagnosed with GDM in the language of their choice.

Thematic analysis was conducted to identify common patterns and salient themes within and across narratives, also taking into account any divergent experiences.
Health care providers faced challenges in managing GDM without prescribing insulin therapy to South Asian women. The biggest challenge faced was diet related, followed by exercise, and weight management.

Women felt diet related information received was culturally inappropriate. They were thus seeking GDM management information from friends and family. Women felt ‘deprived of having good food’ in pregnancy and felt ‘loss of control’ over their pregnancy, as they were preoccupied with testing and maintaining sugar levels. 

Cultural advocates aware of South Asian dietary preferences should provide information relating to lifestyle and behaviour change in GDM management.  Information on GDM and its management should be made available in some of the major South Asian languages.

1. Bandyopadhyay M, Small R, Davey MA, Oats JJN, Forster D, Aylward A.  Lived experience of gestational diabetes mellitus among immigrant South Asian women in Australia.  ANZJOG, 2011; 51(4): 360-364.
2. Setji T, Brown A, Geinglos M.  Gestational diabetes.  Clinical Diabetes 2005; 23:17-24.
3. Jovanovic L, Pettitt DJ.  Gestational diabetes mellitus.  JAMA 2001; 286:2516-18.
4. Bellamy L, Casas J-P, Hingorani AD, Williams DR.  Type 2 diabetes mellitus after gestational diabetes: a systematic review and meta-analysis.  The Lancet 2009; 373:1773-79.
5. Davey RX. Gestational diabetes mellitus: A review from 2004.  Current Diabetes Reviews 2005; 1(2):203-13.

Researchers: A/Prof Helen McLachlan, Prof Della Forster, A/Prof Lisa Amir, Prof Rhonda Small, Dr Meabh Cullinane, Dr Touran Shafiei and Ms Lael Ridgway

Partners: Department of Education and Early Childhood Development, 10 Victorian Local Government Areas

Breastfeeding provides infants with the optimal start to life, yet Victorian breastfeeding rates fall well below national targets and there are major variations in breastfeeding rates across the state. The Victorian Government is committed to increasing breastfeeding rates in Victoria by addressing this important health inequity. The Department of Education and Early Childhood Development (DEECD) has provided funding to Mother & Child Health Research (MCHR) in the Faculty of Health Sciences to trial interventions aimed at increasing breastfeeding duration in Victorian communities. This trial, called SILC (Supporting breastfeeding In Local Communities), is a three-arm cluster randomised trial. It will determine whether early home-based breastfeeding support by a SILC Maternal and Child Health Nurse (SILC-MCHN) for women requiring extra support with breastfeeding, with or without access to a community-based breastfeeding drop-in centre, increases the proportion of infants receiving ‘any’ breast milk at four and six months.

Eligible Local Government Areas (LGAs) across Victoria with low breastfeeding rates have been invited to participate. LGAs agreeing to participate have been randomly allocated to one of three trial arms: standard care (acting as comparison communities); early home-based breastfeeding support by a SILC-MCHN; or access to a community-based breastfeeding drop-in centre in addition to home-based breastfeeding support by a SILC-MCHN.

SILC will assess breastfeeding outcomes using routinely collected Maternal and Child Health Centre data as well as from postal surveys to women in the participating LGAs. The intervention programs have been pragmatically designed so that if such an intervention did increase breastfeeding duration, then it would be able to be readily incorporated into practice in Victoria.