Mother and infant health

Mother and infant health and maternity services research

Program Leads: Professor Della Forster, Professor Helen McLachlan

JLC has a long history of researching mother and infant health and wellbeing, as well as exploring how maternity services are provided in hospitals and elsewhere. This includes work related to women’s and care providers’ views and experiences. Our aim is for our research to make sure we achieve the best possible outcomes 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.

In 2019 two projects relating to our ongoing work introducing and testing caseload midwifery care were rewarded. (Caseload care is an approach that assigns one midwife, or a small team of midwives, to a pregnant woman for the whole of the perinatal period.)

  • We received a La Trobe Excellence in Health Research and Translation Award for our ongoing work in this area, which began with the COSMOS trial. Starting in 2007, it compared standard midwifery care with one-to-one midwifery support. Since then, it has become the world’s largest randomised trial of caseload midwifery and is now the gold standard in maternity care helping to reduce the number of caesareans as well as increasing women's satisfaction with their care.
    The COSMOS findings have assisted policy-makers and maternity services in planning for future models of maternity care in Australia. They now underpin government policies and guidelines. The research has stimulated wider uptake and implementation of the model, particularly in Australia. 
  • The collaborative partnership project Woman’s Journey: Baggarrook Yurrongi, Nurragh Manma Buliana, received the Victorian Public Healthcare Award in the category ‘Improving Aboriginal Health’.

Woman’s Journey: Baggarrook Yurrongi, Nurragh Manma Buliana

Improving the health of Aboriginal and Torres Strait Islander mothers and babies through midwifery continuity of care

We are exploring the capacity of maternity services to implement a new, culturally safe model of care for Aboriginal and/or Torres Strait Islander women (or women having an Aboriginal and/or Torres Strait Islander baby). In this model, women are proactively offered ‘caseload' midwifery: they receive care from the same midwife throughout pregnancy, labour, birth and after birth. The study is also researching women's experiences of care and the effect this model has on the health and well-being of Aboriginal women and their infants. Midwives' views and experiences are another part of the study.

Research team: Helen McLachlan, Della Forster, Michelle Newton, Catherine Chamberlain, Fiona McLardie-Hore, Pamela McCalman; in collaboration with Sue Kildea, Charles Darwin University; Jane Freemantle, Ngaree Blow, Karyn Ferguson and Jeremy Oats, University of Melbourne; Jennifer Brown, Deakin University; Georgia Dickinson, Victorian Aboriginal Community Controlled Health Organisation; Marika Jackomos, Mercy Hospital for Women; Sue Jacobs and Jenny Ryan, the Royal Women’s Hospital; Susan Donath, Murdoch Children’s Research Institute; Lisa Gold, Deakin University

This is a 5-year NHMRC funded Partnership Project with the Victorian Aboriginal Community Controlled Health Organisation (VACCHO), the Royal Women’s Hospital, the Mercy Hospital for Women, Sunshine Hospital (Western Health) and Goulburn Valley Health.

The model was introduced at the Royal Women’s Hospital in March 2017, Sunshine Hospital in October 2017 and the Mercy Hospital in April 2018. It has resulted in a major increase in the number of Aboriginal women having access to caseload midwifery.

A highlight of the project was the project team winning a Victorian Public Healthcare Award in 2019 in the category Improving Aboriginal Health. The project was featured in this short video [external link].

Find details about this study on the Woman's Journey webpage

Sustainability of caseload midwifery (ECO study)

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 a midwife who cares for them before, during and after birth. Researchers from the JLC led the largest randomised controlled trial of caseload care. They found that infants whose mothers were allocated to caseload were less likely to be admitted to the special care nursery and  have low birthweight and were more likely to commence breastfeeding.

In the caseload model, each midwife carries a ‘caseload’ of women, to whom she provides care throughout the antenatal, intrapartum and postnatal periods. She works with two or three other midwives to form a small group, with each providing back up care for the others. This model of care is being promoted as the ‘gold standard’ of care. An increasing number of hospitals are introducing the model.

A study undertaken in Victoria found that midwives working in caseload were more satisfied and less burnt out than their standard care counterparts. There was some evidence, though, that not all midwives want to work in this way, suggesting that the sustainability of the model needs exploration. Very little is known about the workforce implications, and therefore the possible scale and sustainability of this style of care.

Research team: Michelle Newton, Kate Dawson, Della Forster, Helen McLachlan

We found that there is widespread support for and willingness to work in the model. This was influenced by the factors that midwives saw as important to them: midwives who wanted to work in caseload cited flexibility, autonomy and the opportunity to build relationships with women as motivating; those not interested in caseload work preferred shift work and knowing their work commitments ahead of time, and also valued the type of care they provide in standard care models. Exposure to caseload can influence midwives’ views of the model in both positive and negative ways.

The outcomes paper [external link] was published in 2020 in the journal Women and Birth.

Caseload midwifery care for socially vulnerable women

Investigating the feasibility of conducting an international multi-site randomised controlled trial to test if primary midwife-led care improves outcomes for socially vulnerable women

This study explored if it was feasible to conduct an international research study to test if caseload midwifery care improves outcomes for socially vulnerable women. Caseload midwifery is a model of maternity care where women have continuity from a ‘known’ midwife during pregnancy, labour, birth and postpartum. For women who are socially disadvantaged or vulnerable, key perinatal outcomes are poorer overall than for women who are not from these groups, however, there have been no randomised trials of caseload midwifery care for socially vulnerable groups in Australia or elsewhere.

For our feasibility study we conducted interviews with 70 pregnant women similar to those we would approach in a trial.

Research team: Helen McLachlan, Della Forster, Touran Shafiei, Michelle Newton, Molly Allen, Fiona Faulks; in collaboration with Jane Sandall, King’s College, London; Mia Ahlberg, Karolinska Institute, Stockholm

This research was supported by a La Trobe University Building Healthy Communities Research Focus Area grant.

We found that the vast majority of women agreed that they would like to be offered caseload if it was offered in the future and would be willing to participate in a randomised trial. Our study also demonstrated strong commitment from our clinical partners to implement caseload for socially vulnerable women in a randomised trial.

Group antenatal care and education (GEM Care)

Researching the feasibility and acceptability of group antenatal care and education

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 [external link] 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 randomised controlled trial (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.

Research team: Della Forster, Robyn Matthews, Rebecca Hyde; in collaboration with Kaye Dyson, Deborah Fox and Trish Ryan, the Royal Women’s Hospital

The study received funding from the Royal Women’s Hospital.

Women allocated to group care rated their pregnancy care overall very highly, and the pilot demonstrated that a larger, adequately powered RCT is feasible and acceptable to women.

Pregnancy and childbirth experiences of women with a disability (ABLE study)

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.

There is a limited amount of qualitative research focusing on the experiences of pregnancy and childbirth of women with a disability. And there is no 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 with a disability while pregnant, during labour and birth and the early postnatal period.

Research team: Charlie Smithson, Helen McLachlan, Della Forster , Michelle Newton

The study receives funding from the Royal Women’s Hospital.

An online community of support for emotional health in pregnancy (IVY study)

Developing and testing 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

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.

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.

Research team: Della Forster, Touran Shafiei, Helen McLachlan, Laura Biggs, Sara Couch; in collaboration with Terri Smith, Cathy Wyett, PANDA; Greg Wadley, University of Melbourne

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

This study is supported by the Norman Beischer Medical Research Foundationm and by a Building Healthy Communities RFA grant from La Trobe University.

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

Testing whether proactive peer support by telephone decreases the risk of postnatal depression at six months postpartum in new mothers

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. The DAISY study is a multi-site, two-arm randomised controlled trial (RCT) matching peer volunteer mothers, who have experiences postnatal depression and/or anxiety (from which they have recovered), with new mothers who are at increased risk of postnatal depression 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 aim to train about 200 peer volunteer mothers to provide the telephone support.

Research team: Della Forster, Helen McLachlan, Touran Shafiei, Jan Nicholson, Jessica Bee, Méabh Cullinane, Heather Grimes, Catina Adams; in collaboration with Alan Shiell, La Trobe University School of Psychology and Public Health; Cindy-Lee Dennis, University of Toronto; Tram Nguyen, the Royal Women’s Hospital; Cattram Nguyen, Murdoch Children’s Research Institute; Jane Fisher, Monash University; in collaboration with Hume and Wyndham Local Government Areas (LGAs), the Royal Women’s Hospital and PANDA (Perinatal Anxiety and Depression Australia)

This research is supported by a NHMRC Project Grant.

For more information and/or should you be interested in volunteering, see the DAISY webpage.

Evaluation of the Maternity and newborn emergencies (MANE) program

Evaluating the effectiveness of MANE training programme in relation to: clinician confidence, skills and knowledge; changes in teamwork and collaboration; and consumer experience and satisfaction

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.

Research team: Della Forster, Méabh Cullinane, Helen McLachlan, Michelle Newton, Stefanie Zugna

This study receives funding from the Victorian Department of Health and Human Services.

The protocol for an evaluation of the MANE program [external link] was published in 2020 in the journal BMJ Open.

Diabetes and antenatal milk expressing (DAME study)

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. 635 women in six different hospitals took part in this study between 2011 and 2015 - about half of them were advised to express. 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.

Research team: Della Forster, Lisa Amir, Anita Moorhead, Christine East; 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; Lisa Gold, Deakin University

This research was supported by a NHMRC Project Grant and the support of La Trobe University.

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 results of our study should not be extrapolated to high-risk groups with diabetes in pregnancy.)

The findings pave the way for clinicians to recommend that low-risk pregnant women with diabetes in pregnancy express and store breast milk to give to their newborns in the event they develop hypoglycaemia (low blood sugar levels) – a condition that can cause serious health problems in newborns.

The study results [external link] were published in The Lancet in 2017. 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.

Find out more about this project on the DAME webpage.

Collaborative work

Birthplace in Australia

Comparing the safety of planned birth at home, in birth centres and in stand-alone midwifery units with standard labour wards in Australia

Each year in Australia more than 7,500 babies are born outside conventional labour wards, either in birth centres or at home. However, there has been limited evidence on the safety of these alternative settings.

Birthplace in Australia was a population-based retrospective study which compared 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. This was the first Australia-wide study to examine outcomes by planned place of birth and provided important evidence regarding the safety of births planned in hospital, birth centre and at home.

Research team: 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

This research was supported by a NHMRC Project Grant.

Compared with planned hospital births, the odds of normal labour and birth were over twice as high in planned birth centre births and nearly six times as high in planned home births. There were no statistically significant differences in the proportion of intrapartum stillbirths, early or late neonatal deaths between the three planned places of birth.

The results [external link] were published in 2019 in the journal BMJ Open.

The cross-country ultrasound study (CROCUS)

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.

Research team: Kristina Edvardsson, Rhonda Small, Maggie Flood, Christine East; 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, Norway

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.

The study was funded by the Swedish Research Council for Health, Working Life and Welfare (FORTE), the FORTE Marie Curie International Postdoc Fellowship and the Swedish Research Council

This study has resulted in more than 15 publications.

Birth outcomes among migrant women in Sweden and Norway

Researching 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

Migrant women constitute a significant minority of women who give birth in Scandinavian countries. In Sweden and Norway they make up 28% and 27% of births annually. Up to now, the focus of research has been 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.

This research is adding to existing knowledge by including more detailed information on migration than has been done before (paternal origin, length of residence, reasons for migration), using population-based register data from Sweden and Norway.

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

Enhancing maternity care for migrants (EMMA)

Developing and testing innovative models of maternity care for migrant women 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 aims to assess the acceptability and feasibility of group-based antenatal care, supported by childbirth-trained interpreters, for Somali women in the regional city of Borlänge and in a suburb of Stockholm, Spånga-Tensta.
  • Study 2 is a retrospective evaluation of a bilingual doula support program, investigating birth outcomes for migrant women who received support in labour in Gothenburg in the period 2008 to 2016, with birth outcomes for migrant women who experienced usual care for labour and birth without doula support, and with birth outcomes for Swedish-born women giving birth during the same time period.
  • Study 3 is a randomised trial of bilingual doula support to evaluate 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. It involves an interpreter-facilitated hospital visit with a labour ward midwife during pregnancy, aims to assist non-Swedish speaking migrants familiarise themselves with how care for birth is provided in Sweden, providing an opportunity for information exchange during a visit to the labour ward where women will give birth.

Research team: Rhonda Small, in collaboration with Erica Schytt, Helena Lindgren, Ewa Andersson, Malin Arhne, Anna Wahlberg and Amani Eltayb, Karolinska Institute, Sweden; Ulrika Byrskog and Birgitta Essen, Uppsala University, Sweden

This study is supported by the Swedish Research Council and Stockholms Läns Landsting.

Exploring midwives’ and nurses’ perceptions of ‘expertise’ (EXPert study)

Working out a functional definition of expertise within the midwifery and nursing workforce and exploring midwives’ and nurses’ experiences of work

In Australia the concept of ‘expertise’ within the midwifery and nursing workforce is traditionally based on number of years that the clinician has been practicing. As the number of years in the workforce increases, so does the level of compensation. Anecdotally though, when managers are arranging staffing for a given roster or shift, they may view each staff member not simply based on the number of years they have been practicing but also in terms of how much of an ‘expert’ they consider the staff member to be. 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? There is a significant lack of research and understanding in this area.

Concurrently, recent evidence shows an increasing prevalence of midwives’ and nurses’ expressing stress and dissatisfaction about their work. At the Royal Women’s Hospital in Melbourne, Victoria, there were anecdotal reports of increased staff dissatisfaction, worries about staff skill mix, and concerns about potential poor workforce retention among midwives and nurses. Given all these factors, we wanted to explore these issues, and also look at what factors positively or negatively affect staff experiences.

The purpose of the ‘EXPert’ study is to develop a functional definition of expertise within the midwifery and nursing workforce (that can be applied to recruitment, rostering, supporting staff, skill mix and workforce strategies) and to explore midwives’ and nurses’ experiences of work and what factors affect their views.

Research team: Della Forster, Robyn Matthews, Rebecca Hyde, Touran Shafiei, Michelle Newton; in collaboration with Fleur Llewelyn, the Royal Women’s Hospital

The study receives funding from the Royal Women’s Hospital.

Experiences of neonatal intensive or special care (Your Views Matter study)

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

Consumer satisfaction is now a fundamental aspect of evaluating the delivery of health care services in today’s society. Traditionally, long term outcomes of neonatal intensive care were measured mainly in relation to clinical indicators, but consumer satisfaction is increasingly becoming a quality of care indicator for paediatric and neonatal units. Past explorations of families’ experiences of neonatal care at the Women’s have been limited and have not included all families whose babies have been admitted to the neonatal intensive or special care (NISC).

The aim of this study was to explore the satisfaction, experiences and needs of parents whose babies had been admitted to NISC at the Women’s, in order to inform the way future care is provided.

A cross-sectional survey was undertaken. Families who had a baby or babies admitted to NISC were assessed for eligibility (admitted ≥ 4 hours and discharged from NISC by 6 months of age). Eligible families were sent a survey in the mail followed by three reminders. Families who had experienced the death of their baby during their admission were also included in the study and were sent a more tailored invitation to participate, followed by a modified survey if they indicated they would like to participate. A total of 1,014 surveys (or invitations to participate) were sent out. 31% (312/990) of non-bereaved families who were contacted participated in the study, and 57% (4/7) of bereaved families.

Research team: Rebecca Hyde, Della Forster, Touran Shafiei, Anita Moorhead, Helen McLachlan; in collaboration with Susan Jacobs and Laura Bignell, the Royal Women’s Hospital; Silvana Favorito, Consumer

The study received funding from the Royal Women’s Hospital.

Families had high levels of satisfaction with care, however level of satisfaction differed depending on gestation of baby at birth: lower infant gestational age was associated with higher parental satisfaction.