Collaborative Work

Diabetes and antenatal milk expressing (DAME): a randomised controlled trial

Della Forster, Lisa Amir and Anita Moorhead, in collaboration with Susan Jacobs and Peter Davis, Royal Women's Hospital; Susan Walker, Kerri McEgan and Gillian Opie, Mercy Hospital for Women; associate investigators Susan Donath, Royal Children's Hospital, Rachael Ford, Royal Women's Hospital, Catherine McNamara, Mercy Hospital for Women and Amanda Aylward, Royal Women's Hospital

Diabetes is increasing globally and occurs in 8% of pregnancies. These pregnancies are considered to be at high risk of perinatal complications. Infants of women with diabetes in pregnancy have an increased risk of developing diabetes and being obese later in life, and are highly likely to be exposed to cow's milk protein early, also increasing the risk of diabetes. Many maternity providers encourage these 'high-risk' women to express colostrum before birth to have breast milk available should the infant need supplementary feeding to treat hypoglycaemia.

Pilot data from our group and another small study in the United Kingdom found increased special care nursery (SCN) admissions in infants of mothers who expressed antenatally, and the UK study found a one-week reduction in pregnancy gestation. Evidence for this practice is lacking so we are undertaking a multi-site, two-arm randomised controlled trial (RCT) of antenatal expression of colostrum in late pregnancy for women with diabetes in pregnancy to explore the safety and efficacy for mother, fetus and infant. The sites are the Mercy Hospital for Women and the Royal Women's Hospital.

We will test a primary hypothesis that infants of women with diabetes in pregnancy who commence antenatal expressing of colostrum from 36 weeks' gestation will be more likely to be admitted to the SCN/NICU after birth compared with infants of women with diabetes in pregnancy who receive standard care. We will also test whether antenatal expressing increases the proportion of infants receiving exclusive breast milk during the hospital stay after the birth and at three months of age, and whether it decreases duration of pregnancy. We will recruit 658 women to the study.

FUNDING: NHMRC project grant 2011–2014
STATUS: Recruitment underway

More Information: DAME website

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Supporting breastfeeding In Local Communities (SILC project)

Helen McLachlan, Della Forster, Lisa Amir, Rhonda Small, Meabh Cullinane and Touran Shafiei

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 trial interventions aimed at increasing breastfeeding duration in Victorian communities. This trial, called SILC, 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 with identified breastfeeding issues, 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 will be 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. The intervention programs have been pragmatically designed so that if such an intervention did increase breastfeeding, then it would be able to be readily incorporated into practice in Victoria.

FUNDING: Department of Education and Early Childhood Development, 2011 – 2014
STATUS: Ethics approvals obtained, project development in progress

More Information: SILC website

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Perinatal outcomes following treatment for cervical dysplasia

Fiona Bruinsma in collaboration with Michael Quinn, Gynaecological Oncologist, Royal Women’s Hospital

The aim of this project was to measure preterm birth, perinatal death and low birthweight in births to women who were referred to the Dysplasia Clinic at the Royal Women’s Hospital from 1982-2000 after a diagnosis of biopsy-proven precancerous changes of the cervix, and to compare their risk of these outcomes with the risks in the whole Victorian population. The study was a retrospective cohort study in which records from the Dysplasia Clinic were linked to birth records in the Victorian Data Collection for the years 1983-2002. The analysis of the linked data files took into account other risk factors for preterm birth present in the birth data (e.g. maternal age at birth, country of birth, parity, gravidity, socio-economic status) as well as the severity of the cervical lesions, the extent of treatment required and the treatment modality. The study found that diagnosis of pre-cancerous changes in the cervix (regardless of treatment) was associated with an increased risk of preterm birth.

FUNDING: NHMRC project grant 2003-2004

STATUS: one paper published, thesis completed and doctorate awarded (FB) in 2010

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Birth outcomes and maternal and perinatal morbidity associated with induction and augmentation of labour in uncomplicated first births

Mary-Ann Davey, Judith Lumley, James King

Routinely collected data on all births in Victoria in 2000-2005 was analysed to explore the association between induction of labour in the absence of medical indication, and method of birth and maternal and perinatal morbidity. The study included data on 42,950 women having a first baby at 37 to 40 weeks’ (259-286 days) gestation following an uncomplicated pregnancy. Multiple logistic regression was used to adjust the relationships of interest for a number of potential confounding factors (maternal age, baby’s birthweight, gestation, use of epidural analgesia, public or private admission status). Women whose labour was induced were significantly more likely to have a caesarean section or instrumental vaginal birth; and to experience a postpartum haemorrhage and perineal trauma requiring repair. Their babies were more likely to require admission to nursery care and to require active resuscitation at birth. Oxytocin infusions in particular were associated with an increase in shoulder dystocia, postpartum haemorrhage and neonatal jaundice requiring phototherapy.

These findings will inform future interventions and trials aimed at reducing these adverse outcomes.

FUNDING: Initially funded by an Australian Postgraduate Award; currently none.

STATUS: Doctoral thesis passed (M-AD); findings presented at several international scientific meetings in 2010; papers in preparation.

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Early Births – a case-control study of very preterm birth

Lyn Watson, Judith Lumley, Jo Rayner previously in collaboration with Emeritus Professors Judith Lumley, and David Henderson-Smart, and Honorary Professorial Fellow James King

This study that aimed to describe (a) the social and demographic associations of very preterm birth in singletons and twins in Victoria (including those with gestational age); (b) the clinical subtypes of very preterm birth in both singletons and twins in Victoria; and (c) to provide preliminary information on the contributions of exposure to violence, infertility and infertility treatment and neighbourhood level factors to very preterm birth in Victoria has now been completed. The cases are mothers of babies born between 20 and 32 weeks gestation and their characteristics were compared with those of the control mothers selected from the Victorian population whose babies were born at 37 weeks gestation or later. Data collection included a semi-structured interview, either face-to-face or by telephone, and medical record data extraction.

Publishing the findings has been the activity for 2010. Two papers on the study findings from the singleton arm have been published, one submitted and two further in preparation. The findings from the twin arm were presented at a MCHR seminar in July and a paper is in preparation.

FUNDING: NHMRC project grant 2001-2003, SIDS & Kids Victoria 2003-2004 and Faculty Health Sciences Research Enhancement Grant, La Trobe University 2003, Telstra Community Development Fund 2003

STATUS: Data collection complete, data analysis complete, six papers published, one under review, three in preparation

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MILC (mothers’ and infants’ lactation cohort): a multi-site study

Della Forster, Lisa Amir and Helen McLachlan, in collaboration with Anita Moorhead, Helene Johns and Rachael Ford (Royal Women’s Hospital), Kerri McEgan (Mercy Hospital for Women), and Chris Scott (Frances Perry House) and Kinga Pemo (Division of Nursing and Midwifery La Trobe University)

A prospective cohort study is underway. One thousand women who plan to breastfeed are being recruited from three hospitals (MHW, FPH, and RWH) before discharge home.

A high proportion of women in Australia initiate breastfeeding but many stop in the early months. Anecdotally more women are leaving hospital feeding their babies expressed breast milk, and continuing to do so at home. Little is known about the effect of expressing breast milk on a longer term basis in terms of breastfeeding outcomes and other factors such as maternal fatigue, stress and anxiety.

We are using three methods to explore this issue. Firstly, we conducted audits at the Mercy Hospital for Women (MHW), the Royal Women’s Hospital (RWH) and Frances Perry House (FPH), and found that only 35% of women having their first baby were leaving hospital fully attaching and feeding from the breast. Sixty percent of those who were not having a first baby were fully attaching and feeding. We subsequently conducted focus groups with midwives from each site to ascertain their views on the expression of breast milk in the early postpartum period, and found two global themes emerged: the normalisation of expressing and the pressured postnatal environment.

The study involves completion of an initial structured interview to collect demographic details, breastfeeding intentions and current feeding details. Other relevant information is collected from the medical record with the woman’s consent. Structured telephone interviews are being conducted at three and six months postpartum. The primary outcome for comparison is feeding any breast milk at six months. Secondary outcomes include exclusive breastfeeding, maternal confidence and satisfaction with infant feeding.

FUNDING: La Trobe University Faculty Grant

STATUS: Two of three components completed. Minor thesis submitted (KP). Cohort study: recruitment and data collection commenced. Paper from first two components in preparation.

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The role of micro-organisms (S. aureus & C. albicans) in the pathogenesis of breast pain and infection in lactating women (CASTLE Study)

Lisa Amir and Meabh Cullinane, in collaboration with Suzanne Garland and Sepehr Tabrizi, Bio21 Molecular Science & Biotechnology, University of Melbourne, Susan Donath, Murdoch Children’s Research Institute, and Catherine Bennett, Deakin University

This project is a descriptive study of 400 breastfeeding women, recruited from the Royal Women’s Hospital and Frances Perry House. The aim of the study is to investigate the role of micro-organisms in nipple and breast pain in breastfeeding women. At present, there is controversy about whether burning nipple pain associated with radiating breast pain is caused by fungal infection (Candida albicans, known as “thrush”) or bacterial infection (Staphylococcus aureus, known as “golden staph”).

Swabs will be collected from mothers’ noses and nipples and their babies’ mouths. Breast milk will also be collected. These samples will be collected after the birth, then once per week for four weeks. Women will also complete questionnaires at recruitment, then weekly postpartum for four weeks. The study will conclude with a telephone interview at eight weeks postpartum, to collect further information about breastfeeding problems such as nipple and breast pain.

FUNDING: NHMRC Health Professional Research Fellowship 2006-2010 (LA); NHMRC project grant 2009-2010; NHMRC equipment grant (2009/2010)

STATUS: Recruiting commenced October 2009

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Breastfeeding women’s use of breast pumps: A descriptive study

Lisa Amir and Sarah Clemons in collaboration with the Australian Breastfeeding Association

There is a trend in Australia and other developed countries where mothers are increasingly expressing breast milk. However there is limited research as to the reasons women express breast milk and use breast pumps. This study provides descriptive information on breastfeeding women’s use of pumps and their experiences of expressing breast milk. A survey of Victorian members of the Australian Breastfeeding Association was conducted online in 2008.

FUNDING: None

STATUS: Survey conducted, one paper published in 2010

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Collaborative Work

Advanced maternal age: Analysis of routinely-collected data on all births to women aged 35-44 in Victoria in 2005 and 2006, comparing interventions, method of birth and maternal and neonatal morbidity compared with those to women aged 25-29 years.

Mary Carolan, Mary-Ann Davey, Michelle Kealy, Mary Anne Biro

FUNDING: none

STATUS: analysis underway; one paper published in 2010 and other papers in preparation

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Dying to be counted: A mortality profile of Victoria’s Aboriginal (and non-Aboriginal) children, 1998-2008 using an innovative method and research process

Ian Anderson (CI), Jane Freemantle, Joan Ozanne-Smith, Jane Halliday, Jill Gallagher, Mary-Ann Davey, May Sullivan, Pam Muth

FUNDING: ARC

STATUS: ongoing; one report published in 2010

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