Mother and infant health

Mother and infant health and maternity services research

JLC research in the area of pregnancy and birth focuses on ensuring that the best possible outcomes are achieved for women and their infants. Some of our studies focus on specific groups of women, for example immigrant women or other vulnerable groups, other studies look more broadly. We are undertaking many state-wide and national studies in this area, mostly with a focus on describing and improving current practice. An additional area of focus is ensuring that the views of clinicians providing care (such as midwives and doctors) are taken into account.

The ABLE study (asking women about disabilities)

Exploring the prevalence and experiences of women with disabilities who use maternity services at the Royal Women’s Hospital in Victoria, Australia

It is estimated that more than one billion people worldwide are living with a disability. However, limited information exists on the disability status and needs of women during pregnancy. In Australia, disability status is not included in the Perinatal National Minimum Data Set.

While there is a limited amount of qualitative research focusing on the experiences of pregnancy and childbirth of women with a disability, there is an absence of quantifiable data. We aim to address this gap by exploring the prevalence and identification of women with disabilities who utilise maternity services. We will also gain insight into the experiences of women who identify as having a disability about how they found their pregnancy, labour and birth and the early postnatal period.

researchers Helen McLachlan, Della Forster, Michelle Newton, Charlie Smithson
funding The Royal Women’s Hospital

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

This world first study has found that women with diabetes in a low-risk pregnancy can safely express breast milk in late pregnancy, with the study dispelling concerns that the practice could cause harm to babies.

The DAME study explored the safety and effectiveness of advising women with diabetes in pregnancy to commence expressing breast milk from 36 weeks of pregnancy. We recruited a total of 635 women and randomised them to the study – about half of them were advised to express. We recruited the women at six sites that provide pregnancy and birth care: The Royal Women’s Hospital, Mercy Hospital for Women, Monash Health, Barwon Health, the Women’s at Sandringham (part of the Royal Women’s Hospital) and Frankston Hospital, from June 2011 until October 2015. We collected data at recruitment in late pregnancy as well as from birth records, and then by telephone interview at two weeks and 12 weeks after birth.

The study found that for women with diabetes in pregnancy who were considered of low obstetric risk, there was no harm in advising them to express breast milk in late pregnancy. We also found evidence that infants were more likely to receive only breast milk in the first 24 hours after birth.

The study results were published in The Lancet in 2017, and clinical guidelines have been developed based on the study outcomes.

A sub-study titled Exploring mothers’ perceptions of their experience of antenatal milk expressing commenced in early 2017.

researchers Della Forster, Lisa Amir, Anita Moorhead; in collaboration with Susan Jacobs, Peter Davis, Amanda Aylward and Rachael Ford The Royal Women’s Hospital; Susan Walker, Kerri McEgan, Gillian Opie and Catherine McNamara, Mercy Hospital for Women; Susan Donath, Murdoch Children’s Research Institute; Christine East, Monash Medical Centre; Lisa Gold, Deakin University
websiteDAME website
funding NHMRC Project Grant; La Trobe University

ECO – Exploring the introduction, expansion and sustainability of caseload midwifery in Australia

Caseload midwifery is a maternity model of care, which aims to provide women with continuity of care from a known midwife. There is strong evidence that caseload care decreases birth interventions (e.g. caesarean births, analgesia in labour), increases women’s satisfaction with care and improves infant outcomes. This model of care is being promoted as the ‘gold standard’ and an increasing number of hospitals are introducing the model. However, very little is known about the workforce implications, and therefore the possible scale and sustainability of this style of care.

The ECO study aims to explore the sustainability of caseload midwifery in Australia. This cross‐sectional study involved a national survey of 149 maternity managers and 542 midwives from all public maternity hospitals in Australia and a survey of 129 Victorian graduating midwifery students.

researchers Michelle Newton, Kate Dawson, Della Foster, Helen McLachlan

Primary midwife-led care for migrant and refugee women

Exploring the feasibility of conducting an international multi-site randomised controlled trial to test if primary midwife-led care improves outcomes for migrant and refugee women

Compared with non-immigrant women, those having a baby in a new country have more negative birth experiences, and many have poorer maternal and infant outcomes. Possible factors include suboptimal care (e.g. fewer visits, less screening), discrimination, cultural/language issues, financial stress, poor supports, and difficulty navigating health systems.

Caseload midwifery (primary midwife-led care) where women have continuity from a ‘known’ midwife during pregnancy, labour, birth and postpartum, is associated with better clinical and psychosocial outcomes, however few migrant and refugee women have access to caseload care.

In partnership with researchers in the United Kingdom and Sweden, we are conducting a feasibility study for an international multi-site randomised trial to test if primary midwife-led care improves outcomes for migrant and refugee women.

researchers Helen McLachlan, Touran Shafiei, Della Forster, Michelle Newton, Molly Allen; in collaboration with Jane Sandall, King’s College, London; Mia Ahlberg, Karolinska Institute, Stockholm; Regina Quiazon, Multicultural Centre for Women’s Health
funding Building Healthy Communities Research Focus Area

GEM Care - Exploring the feasibility and acceptability of group antenatal care and education

A pilot randomised controlled trial

Group-based antenatal care, pregnancy care and childbirth / parenting education is undertaken in groups of 8–10 women for 6–8 sessions with two midwives. Evidence regarding potential benefit or harm is inconclusive, with some suggestion the model is associated with fewer preterm births. A Cochrane review concludes more evidence is needed.

We aimed to test the feasibility of implementing an adequately powered randomised controlled trial (RCT). For this we conducted a two-arm pilot RCT. Women allocated to the intervention received group-based antenatal care and education (known as GEM Care, Group Education and Midwifery Care). Usual care included hospital-based midwife, caseload or team care, or shared care with a GP. Participants were English-speaking, primiparous, low risk, with no more than 24 weeks gestation at booking. Clinical outcome data were collected from the medical record. A telephone interview at six weeks postpartum explored women’s views. Focus groups explored midwives’ views.

researchers Della Forster, Robyn Matthews, Rebecca Hyde; in collaboration with Kaye Dyson, Deborah Fox and Trish Ryan, The Royal Women’s Hospital
funding The Royal Women’s Hospital

IVY – investigating an online community of support for emotional health in pregnancy

Perinatal mental illness is a major public health issue, with serious and costly health consequences for women, their infants and families. Many women don’t seek help; potential barriers include fear of stigmatisation, fear of failure and lack of support. These barriers may be overcome by more flexible models of support, such as an online peer support program.

This study aims to develop and test the feasibility, acceptability and functionality of a moderated online peer support App to be used on smart phones, tablets or computers, to reduce perinatal depression and anxiety in women at increased risk.

The project has been undertaken in collaboration with PANDA –Perinatal Anxiety & Depression Australia – Australia’s peak consumer perinatal mental health organisation.

An iterative user-centred approach was used to design and develop the App, via a series of interviews, focus groups and design workshops with consumers, stakeholders and software designers. We are preparing to conduct a pilot randomised controlled trial (RCT) to test potential impact and engagement as well as to inform a large adequately powered RCT.

researchers Della Forster, Helen McLachlan, Touran Shafiei, Laura Biggs, Sara Couch; in collaboration with Terri Smith, Cathy Wyett, PANDA; Greg Wadley, University of Melbourne
funding Norman Beischer Medical Research Foundation

Maternity and newborn emergencies (MANE) program evaluation

The Victorian Department of Health and Human Services has funded the Maternity and Newborn Emergencies (MANE) program, which is auspiced and run by The Royal Women’s Hospital Maternity Services Education Program for regional and rural public maternity providers.

To inform the ongoing development of the content, design and delivery of the program, we are conducting an evaluation of MANE over a three-year period from 2017 to 2020. All rural and regional maternity service providers currently receiving MANE have the opportunity to participate, with in-depth case studies conducted at five maternity service sites.


Della Forster, Helen McLachlan, Michelle Newton, Méabh Cullinane, Stefanie Zugna

funding Victorian Department of Health and Human Services

Obstetric outcomes for immigrant women

This project continued earlier work investigating identified problems of public health importance in relation to obstetric outcomes and experiences of maternity care for immigrant women of non-English speaking backgrounds in Australia. These include a range of unexplained variations by maternal country of birth (e.g. in caesarean section and other obstetric procedures); evidence for higher standardised perinatal mortality ratios among well grown term infants of women born in NES-countries; and consistently poorer ratings of maternity care by immigrant women from NES-countries.

In 2017 Fetene Belihu graduated with a Doctor of Public Health with research using VPDC data to investigate a range of perinatal outcomes for East African born women and their infants, supervised by Rhonda Small and Mary-Ann Davey. Analyses examining mode of birth outcomes for Vietnamese-born women over 23 years were also published in 2018.

researchers Rhonda Small, Fetene Belihu, in collaboration with Mary-Ann Davey, Monash University, the Victorian Perinatal Data Collection (VPDC) and Paul Agius, Burnet Institute

Preventing postnatal depression in new mothers using telephone peer support (DAISY)

In Australia, 17% of new mothers experience postnatal depression (PND), with serious health consequences for the woman, her infant and family members. However, one in three Victorian new mothers experiencing PND do not seek help. DAISY (Depression and AnxIety peer Support studY) is a multi-site, two-arm randomised controlled trial (RCT) matching peer volunteer mothers with a lived experience of postnatal depression and/or anxiety (from which they have recovered) with new mothers at increased risk of PND or anxiety.

The aim is to test whether proactive peer support by telephone decreases the risk of PND at six months postpartum. A range of other health outcomes will also be measured, along with exploring the cost-effectiveness of such a service. We will recruit 1,060 women to the study and train about 200 peer volunteer mothers to provide the telephone support.

researchers Della Forster, Helen McLachlan, Touran Shafiei, Jan Nicholson, Heather Grimes, Jessica Bee, Molly Allan, Catina Adams; in collaboration with Alan Shiell, School of Psychology and Public Health, La Trobe University; Cindy-Lee Dennis, University of Toronto; Tram Nguyen, The Royal Women’s Hospital; Cattram Nguyen, Murdoch Children’s Research Institute; Jane Fisher, Monash University; Hume and Wyndham Local Governments and PANDA (Perinatal Anxiety & Depression Australia)
websiteDAISY website
funding NHMRC Project Grant

Collaborative work

Birthplace in Australia: a prospective cohort study

More than 7,500 babies are born outside conventional labour wards, either in birth centres or at home in Australia each year. However, there is limited evidence on the safety of these alternative settings, with concerns being raised about increased risk of stillbirth, early neonatal death, neonatal encephalopathy, meconium aspiration, brachial plexus injury, and fractured humerus or clavicle. High quality evidence about the risks and benefits associated with giving birth in different settings should be available to women, policy makers and those responsible for service provision.

Birthplace in Australia is a prospective cohort study which aims to compare the safety of planned birth at home, in birth centres and in stand-alone midwifery units with standard labour wards in Australia, for women at 'low risk' of complications at labour onset.

researchers Helen McLachlan, Della Forster; in collaboration with Caroline Homer, Maralyn Foureur, David Sibbritt, University of Technology Sydney; David Ellwood, Griffith University; Jeremy Oats, University of Melbourne; Hannah Dahlen, Western Sydney University
funding NHMRC Project Grant

The cross-country ultrasound study (CROCUS)

The CROss-Country Ultrasound Study (CROCUS) is an international research project exploring midwives’ and obstetricians’ experiences and views on the use of ultrasound in pregnancy management in low-, middle-, and high-income countries (Rwanda, Tanzania, Vietnam, Australia, Norway and Sweden). The second quantitative phase of CROCUS was completed in 2016–2017 in Norway, Rwanda, Tanzania and Vietnam, and in 2018 in Australia and Sweden.

This work has led to the Rwandan Ultrasound Health Centre Intervention Study which has been formally approved and supported by the Minister of Health. This project evaluates the inclusion of ultrasound in standard maternity care at health centre level in terms of pregnancy and delivery outcomes, economics and the experiences of women and health care professionals.

researchers Kristina Edvardsson and Rhonda Small; in collaboration with Ingrid Mogren, Sophia Holmlund and Annika Åhman, Umeå University, Sweden; Hussein Lessio Kidanto and Mathilda Ngarina, Muhimbili National Hospital, Tanzania; Pham Thi Lan, Hanoi Medical University, Vietnam; Joseph Ntaganira and Jean Paul Semasaka Sengoma, University of Rwanda, Rwanda; Tove Fagerli and Elisabeth Darj, Norwegian University of Science and Technology, Norwa

14 publications so far, the latest ones being:

Åhman A, Edvardsson K, Fagerli TA, Darj E, Holmlund S, Small R, Mogren I. A much valued tool that also brings ethical dilemmas - a qualitative study of Norwegian midwives’ experiences and views on the role of obstetric ultrasound. BMC Pregnancy Childbirth 2019; 19:33

Åhman A, Edvardsson K, Lesio Kidanto H, Ngarina M, Small R, Mogren I. ‘Without ultrasound you can’t reach the best decision’ – Midwives’ experiences and views of the role of ultrasound in maternity care in Dar Es Salaam, Tanzania. Sex Reprod Healthc 2018; 15:28-34.

Edvardsson K, Åhman A, Fagerli TA, Darj E, Holmlund S, Small R, Mogren I. Norwegian obstetricians’ experiences of the use of ultrasound in pregnancy management. A qualitative study. Sex Reprod Healthc 2018; 15:69-76

Holmlund S, Ntaganira J, Edvardsson K, Lan PT, Semasaka Sengoma JP, Åhman A, Small R, Mogren I. Improved maternity care if midwives learn to perform ultrasound: a qualitative study of Rwandan midwives’ experiences and views of obstetric ultrasound. Glob Health Action 2017; 10:1350451

funding Swedish Research Council for Health, Working Life and Welfare (FORTE); FORTE Marie Curie International Postdoc Fellowship. (Ref. 2013-2699); Swedish Research Council (Ref. 2014-2672)

Enhancing maternity care for migrants: Research to action (EMMA)

This program of work aims to develop and test innovative models of maternity care for migrant women in Sweden in an effort to improve their experiences of antenatal and intrapartum care, their knowledge about childbearing and the health care system, their emotional wellbeing and ultimately, their pregnancy outcomes.

There are four key projects in the program to date. Study 1 assesses the acceptability and feasibility of group-based antenatal care, supported by childbirth-trained interpreters, for Somali women in Sweden. Study 2 is a retrospective evaluation of a bilingual doula support program on birth outcomes for 1500 migrant women. Study 3 is a randomised trial evaluating the effectiveness of community-based doula support for improving the intrapartum care experiences and postnatal wellbeing of Somali, Eritrean, Arabic and Russian-speaking migrant women giving birth in Stockholm. Study 4 is a quality improvement co-designed project for enhancing maternity care for migrant women at Södertälje Hospital, south of Stockholm.

researchers Rhonda Small; in collaboration with Professor Erica Schytt, Helena Lindgren, Ewa Andersson, Malin Arhne, Anna Wahlberg and Amani Eltayb, Karolinska Institute, Sweden; Ulrika Byrskog and Birgitta Essen, Uppsala University, Sweden
funding Swedish Research Council and Stockholms Läns Landsting

EXPert – Exploring midwives’ and nurses’ perceptions of ‘expertise’

The concept of ‘expertise’ within the midwifery workforce is traditionally based on number of years that a clinician has been practicing. As the number of years in the workforce increases so does the level of compensation, suggesting a correlation between time spent since qualifying and increased ability/value. Anecdotally, when arranging staffing, managers also view staff in terms of how much of a perceived ‘expert’ they are. Some staff exhibit a high level of perceived ‘expertise’, yet receive no formal recognition. What is ‘expertise’ from a practical point of view if it means more than just the number of years worked? This study aims to develop a functional definition of exper­tise within the midwifery workforce that can be applied to recruitment, rostering, supporting staff, skill mix and workforce strategies.

researchers Touran Shafiei, Michelle Newton, Della Forster; in collaboration with Robyn Matthews, Rebecca Hyde and Fleur Llewelyn, The Royal Women’s Hospital
funding Royal Women’s Hospital (staff support)

Pregnancy and delivery related complications in Rwanda

Prevalence, associated risk factors, health economic impact and maternal experiences

Rwanda is a low-income country, with maternal mortality estimated to be 201 per 100,000 live births. Since 2014, the Swedish International Development Cooperation Agency has been supporting a large research project on maternal health care in Rwanda. This project includes four PhD studies with the common aim of investigating various aspects of Rwanda’s antenatal care, delivery and postnatal services. This includes quality and utilisation of antenatal care and delivery services, pregnancy and delivery complications and their impact on health and family circumstances, with analyses of cost effectiveness.

Dr Jean Paul Semasaka Sengoma successfully defended his PhD thesis at Umeå University in November 2018. His research examined the prevalence of pregnancy and delivery-related complications, their associated risk factors and their consequences to the woman and her family.

researchers Kristina Edvardsson; in collaboration with Jean Paul Semasaka Sengoma, Umeå University, Sweden/University of Rwanda; Ingrid Mogren, Umeå University, Sweden; Gunilla Krantz, University of Gothenburg, Sweden; Cyprien Munyanshongore and Manasse Nzayirambaho, University of Rwanda
funding The Swedish International Development Cooperation Agency

Register-based studies of birth outcomes among migrant women in Sweden and Norway

Migrant women constitute a significant minority of women who give birth in the Scandinavian countries, in Sweden and Norway contributing 28% and 27% respectively of the births annually. Up to now, research has focussed on women who have migrated from countries with particularly high risk for adverse outcomes and less is known about other large immigrant groups, including those who have arrived more recently.

The aim of this research is to explore the associations between migration and adverse maternal and infant pregnancy outcomes in immigrant and in Swedish- and Norwegian-born women who gave birth between 1990 and 2016 in Sweden and in Norway. It adds to existing knowledge by including detailed information on migration (paternal origin, length of residence, reasons for migration), using population-based register data from Sweden and Norway.

researchers Rhonda Small; in collaboration with Erica Schytt, Sol Juárez, Anders Hjern, Sweden; Vigdis Aasheim, Roy Nilsen, Eline Skirnisdottir Vik, Dag Moster, Svein Rasmussen, Norway

Reproductive outcomes and migration (ROAM): An international collaboration

This collaboration aims to compare migrant, refugee and asylum-seeking women’s reproductive health outcomes and their views of maternity care in Europe, North America and Australia. The collaboration began with an initial grant awarded from the Canadian Institutes of Health Research (CIHR) International Opportunity Development Grant Scheme. The first meeting of a collaborative network of researchers from the UK, Italy, France, Belgium, and Finland was held in 2004. Since then collaborators from a range of other countries have joined the network and annual meetings have been held.

ROAM collaborators met in Paris in June 2017 and in Edinburgh in 2018. Completed work was presented and further collaborative research was discussed.


Rhonda Small, Touran Shafiei
ROAM Steering Group: Birgitta Essen, Uppsala University, Sweden; Rhonda Small, La Trobe University, Australia; Mika Gissler, Institute of Health, Finland; Lisa Merry, McGill University, Canada; Jennifer Zeitlin, INSERM, France, and EURO-PERISTAT; Marcelo Urquia, University of Manitoba, Canada; Sarah Villadsen, University of Copenhagen, Denmark; Sarah Maria Salway, University of Sheffield

Your views matter

Exploring the experiences, satisfaction and needs of parents of infants admitted to Newborn Services at the Royal Women’s Hospital

The Royal Women’s Hospital admits more than 1600 babies to Newborn Services per annum. Around 35% of these babies are discharged home, with the remainder being transferred to a lower level special care unit. Families can suffer long-term consequences from their baby’s stay in neonatal intensive care which last long after the acute admission period and affect the health of individual family members (particularly mothers), family function, and coping with baby care. We aim to explore the satisfaction, experiences and needs of parents whose babies have been admitted to Newborn Services to inform the way future care is provided; and key clinical outcomes at six months (e.g. maternal mental health and infant feeding).

researchers Della Forster, Helen McLachlan, Touran Shafiei, Anita Moorhead, Rebecca Hyde; in collaboration with Susan Jacobs, Laura Bignell and Silvana Favorito, The Royal Women’s Hospital
funding The Royal Women’s Hospital Foundation