COmparing Standard Maternity care with One to one midwifery Support (COSMOS): a randomised trial.

Helen McLachlan, Della Forster, Mary-Ann Davey, Lisa Gold, Judith Lumley, Mary Anne Biro and Michelle Newton in collaboration with Tanya Farrell and Jeremy Oats, Royal Women’s Hospital, Ulla Waldenstrom, Karolinska Institute and Leah Albers, University of New Mexico

Continuity of carer in the provision of maternity care has been strongly recommended and encouraged in Victoria and throughout Australia. The Victorian Department of Human Services (DHS) 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 have 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 has yet to be subjected to rigorous evaluation. "One to one midwifery" or caseload care is being implemented under trial conditions at the Women's hospital. We will evaluate whether caseload midwifery decreases interventions during childbirth (such as caesarean births, instrumental vaginal births, and induction of labour) compared with standard maternity care. We will also compare 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 December 2010.

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

FUNDING: NHMRC project grant 2007-2010

STATUS: Data analysis

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WAVE: Women’s and staff views: an evaluation of maternity care at Barwon Health

Helen McLachlan, Della Forster, Mary-Ann Davey and Jane Morrow, in collaboration with Michelle Newton, Division of Nursing and Midwifery La Trobe University; and Therese Cotter and Kim Layton, Barwon Health

In 2008 Barwon Health implemented two major changes to its maternity service provision: a re-organisation of postnatal care and the implementation of a caseload midwifery model of maternity care. First, postnatal care provision was altered to be a more flexible, individualised model of care focused on promoting the normalisation of the postnatal period. Changes commenced in January 2008 and included encouraging women to self cater for breakfast; to independently care for themselves and their baby where appropriate; promoting rest; providing communal space for socialisation; encouraging and providing group education; cessation of the use of maternal and neonatal clinical pathways to guide care for women who have had a vaginal birth; and implementing a focused time where midwives specifically sit and discuss the education and support needs identified by women themselves instead of undertaking routine postnatal observations. Second, Caseload midwifery (called Midwifery Group Practice (MGP)) was implemented in July 2008. Women receiving caseload care receive antenatal, intrapartum and postpartum care from a primary MGP midwife with one or two antenatal visits (and other care as required) by a ‘back-up’ midwife. MGP midwives collaborate with obstetricians and other health professionals as necessary and provide care until after the birth of the baby and attend for some postnatal care and domiciliary care following discharge from hospital. An evaluation of the changes included three cross-sectional surveys of women (550 at each time point); two cross-sectional surveys of midwives (all midwives in maternity services at each time point); key informant interviews with women, midwives and other key stakeholders; and two focus groups with midwives. Specific aims were to: • Explore the views, experiences and health outcomes of women who gave birth at Barwon Health following the implementation of changes to postnatal care, and the introduction of caseload midwifery, and to compare these to the views, experiences and health outcomes of women who gave birth prior to the changes; and • Explore the views and experiences of the clinicians and other key stakeholders involved in the provision of postnatal care and caseload midwifery.

FUNDING: Department of Human Services Victoria and Barwon Health.

STATUS: Data collection complete, analysis underway, final report and two manuscripts in preparation.

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A review of postnatal care in the Victorian private hospital sector (PinC Private)

Jo Rayner and Della Forster in collaboration with Helen McLachlan and Louise Peters, Division of Nursing and Midwifery, La Trobe University; and Jane Yelland, Murdoch Children’s Research Institute

The first review of postnatal care from the perspective of public hospital care providers (PinC) was undertaken in 2004 and involved a survey of public maternity facilities in Victoria and interviews with key informants from selected hospitals. The findings revealed a diversity of practices in the provision of care across the State, including differences in the organisation of care, staffing arrangements, facilities and routine practices. Barriers to provision of high quality postnatal care were also identified including the busyness of the units, the inadequacy of staff-patient ratios, and the priority given to other episodes of care.

Given that approximately one third of Victorian births occur in the private sector, a review of postnatal care in the private sector (PinC private) was undertaken in 2006 to provide a comprehensive understanding of the structure and provision of postnatal care in Victoria. A postal questionnaire was sent to all private hospitals (n=19) providing maternity services and in-depth interviews were conducted with care providers (n=11) at selected regional and metropolitan hospitals. While the response rate was lower in the private sector (14/19 hospitals, 76%), the postal survey revealed similar barriers to the provision of postnatal care highlighted in the public review, despite some differences in the organisation of postnatal care. Analysis of the interviews suggests a mismatch between women’s expectations of postnatal care and that of care providers in the private sector.

FUNDING: La Trobe University Faculty of Health Science Research Grant 2006, MCHR Grant 2006

STATUS: project complete, two conference presentations in 2007; one paper published in 2010; Masters of Midwifery minor thesis passed (LP)

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PRISM: Program of Resources, Information and Support for Mothers

Judith Lumley, Rhonda Small, Stephanie Brown (now Murdoch Children’s Research Institute), Lyn Watson and Creina Mitchell in collaboration with Jane Gunn, Department of General Practice, University of Melbourne

PRISM was a community intervention trial in 16 municipalities across Victoria which aimed to improve the physical and emotional health of women following childbirth via an integrated program of primary care and community based strategies, implemented in 1999 and 2000, with outcome data collection occurring over three years, from August 2000 to August 2003. Detailed information about PRISM can be accessed on the project website: www.latrobe.edu.au/mchr/prism. The primary outcomes paper which showed no effect of the intervention can be downloaded free at: http://www.biomedcentral.com/content/pdf/1471-2458-6-37.pdf During 2010 final analysis of the two year outcome data was completed and presented at the Annual Conference of the Australasian Epidemiology Association.

FUNDING: La Trobe University and Victorian Department of Human Services Collaborative Industry grant 1997, NHMRC project grants 1997-99, 1999-01 and 2002-04, Victorian Department of Human Services program implementation grants 1998-2000, VicHealth grants for program resources and implementation 1998-2000, Felton Bequest grant 1998, Sidney Myer Fund grant 1999, beyondblue grant 2002 and participating municipalities’ contributions to program implementation and data collection 1998-2003.

STATUS: four papers and 16 municipality reports published; in 2009: conference paper presented on two-year follow-up data and paper in preparation.

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Medicines and breastfeeding women: Knowledge, attitudes and practices of GPs

Lisa Amir and Jeanne Daly, in collaboration with Marie Pirotta, Department of General Practice, University of Melbourne, and Swee Wong, Pharmacy Department, Royal Women’s Hospital

At times, women who are breastfeeding will consider taking medicines. These may include complementary and over-the-counter as well as prescribed medicines. General practitioners tend to rely on pharmaceutical companies for information about medicines. The companies’ usual advice is to be cautious about prescribing medicines to breastfeeding women. However, there are very few medicines which need to be used with caution while breastfeeding. This study aims to investigate general practitioners’ knowledge, attitudes and practices about the use of medicines in breastfeeding women. These issues will be explored using in-depth interviews with a small number of GPs and a survey of a larger group (about 650 people).

FUNDING: Faculty grant 2007

STATUS: Results presented at conferences in 2008; two papers published in 2010, report online http://www.latrobe.edu.au/mchr/Meds%20and%20bf%20report%2020100816.pdf

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What motivates general practitioners (GPs) working in integrated medical practices to use complementary medicines (CM) as treatment modalities?

Jo Rayner in collaboration with Karen Willis, Department of Sociology and Social Work, University of Tasmania and Marie Pirotta, Department of General Practice, University of Melbourne

The use of complementary medicine (CM) as a healthcare option has grown exponentially in Australia and elsewhere. CM is difficult to define as it encompasses a diverse range of beliefs, practices, and treatments. Internationally CM is increasingly being integrated into general medical practice, possibly driven by consumer demand. What motivates general practitioners (GPs) to embrace CM is currently unclear, as is any understanding of what evidence-bases GPs draw on to advise or treat their patients. Most research has focused on why consumers choose CM rather than on provider rationales. Using in-depth interviews, this project aims to investigate the reasons why GPs choose to integrate CM modalities into their medical practice by exploring:

1. GPs views on evidence in their treatment decision making
2. whether there is differentiation in their choice of CM treatment modalities; and
3. the extent to which their reasons for using CM are influenced by consumer demand, economic considerations or dissatisfaction with current treatment options.

FUNDING: Faculty of Health Science Research Grant 2009

STATUS: study complete, one paper under review, presentation at TASA 2010

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The views, experiences, and referral patterns of Victorian fertility specialists regarding fertility enhancement by complementary and alternative medicine (CAM)

Jo Rayner, Helen McLachlan, Della Forster and Michelle Kealy in collaboration with Marie Pirotta, Department of General Practice, University of Melbourne; and David Ellwood, Department of Medicine, Australian National University

Infertility treatment is increasing in Australia and current trends in women’s age at first birth suggest more Australian couples may need to seek assisted reproductive technologies (ART) to achieve parenthood. Increasingly Australians are using complementary and alternative medicines (CAM), often without the knowledge of orthodox medical practitioners, potentially increasing the risk of interactions and adverse effects. There is very little data on the use of CAM in fertility enhancement (e.g. extent of use; costs; women’s willingness-to-pay; what CAM modalities are commonly used; and what proportion of medical fertility specialists refer to CAM practitioners), and limited knowledge of potential side effects of many CAM products, particularly with respect to their use in the periconceptional period. In an anonymous postal survey, this study explored Victorian fertility specialists’ views on women’s use of CAM for fertility enhancement. All medical specialists approved under the Infertility Treatment Act 1995 and listed with the Infertility Treatment Authority (ITA) to practice in Victoria were invited to participate. Nine specialists returned completed surveys, a response fraction of 18%. An attempt to expand the study to include fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) was unsuccessful with permission to conduct the study declined by the RANZCOG Quality Committee.

FUNDING: La Trobe University Faculty of Health Sciences Research Grant 2007

STATUS: one paper published 2010

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A review of home-based postnatal care in Victoria

Helen McLachlan, Della Forster and Heather McKay in collaboration with Tanya Farrell and Rachael Ford, Royal Women’s Hospital and Harriet Morton and Jen Hocking (School of Nursing and Midwifery)

The care women receive after having a baby is likely to have a significant impact on their health and well-being. With the rising number of births, many health services in Victoria (including tertiary referral hospitals) have had to respond by discharging women much earlier than planned or expected. In the public health system women receive one or two home visits by a hospital midwife after discharge, yet there has been no evaluation of home-based postnatal care in Victoria, and there is very little evidence to guide care.

The aim of the project is to explore home-based postnatal care in terms of what is currently provided; what women expect; and how prepared midwives are to provide home-based postnatal care. The project comprises three components. Component one is a web-based survey of all managers of public maternity hospitals in Victoria exploring the guidelines, procedures, and practice of home-based postnatal care. Component two involves interviews with new mothers whose babies are approximately four to five months of age, and who received home-based postnatal care from a public hospital midwife in Victoria. Component three comprises focus groups with Victorian midwives who provide home-based postnatal care.

This ongoing project will provide urgently needed information concerning the structure and content of postnatal home-based care in Victoria.

It is also intended to provide valuable data which will help inform clinical practice, guide policy development and direct future research.

FUNDING: Faculty of Health Sciences research grant 2008

STATUS: Data collection and analysis

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Improving maternal and child healthcare for vulnerable mothers (MOVE)

Angela Taft, Rhonda Small, Catina Adams and Ruby Walter in collaboration with Cathy Humphreys, Department of Social Work and Kelsey Hegarty, Primary Care Research Unit, University of Melbourne

The MOVE pragmatic cluster randomised controlled trial examines whether an enhanced intervention model of maternal and child health nurse care for new mothers experiencing partner violence improves disclosure and referral rates, satisfaction with care and outcomes for mothers and their children.

We combined a systematic review of guidance for community-based nurses with participatory action research involving nurse consultants from the four intervention MCH teams. From this we developed consensus guidelines, strategies and resources for the new model which included the greater involvement of family violence services with maternal and child health nurse teams. The intervention is currently underway and will be completed by April 2011. Toward the end of 2010, we conducted an interim process evaluation online survey (n=127/160, 79%) and semi-structured interviews (n=15) with key stakeholders within the theoretical framework provided by Normalisation Process Theory (May, 2007). The outcomes of the intervention will be examined in a postal survey of 10,000 MCH clients who gave birthover the previous eight months in both the four intervention and four comparison communities. Preparation for this is currently underway.

The model was presented by invitation to the WONCA (World Organisation of National Organisations and Academies of Family Medicine) European conference and pre-conference in Malaga in October 2010.

FUNDING: ARC Linkage Project 2008-2011.

STATUS: Ongoing. Project Coordinator Dr Ruby Walter returned from maternity leave in October.

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