Mother and infant health

CROCUS - The cross-country ultrasound study

Kristina Edvardsson, Umeå University, Sweden/Judith Lumley Centre; Rhonda Small, Judith Lumley Centre; Ingrid Mogren, Umeå University, Sweden, in collaboration with researchers in Sweden, Norway, Vietnam, Tanzania and Rwanda

Obstetric ultrasound examinations have come to play an increasingly significant role in maternity care, and advances in obstetric ultrasound have led to improvements in pregnancy outcomes. However, it has at the same time been argued that the continuing medico-technical progress has led to an increased medicalisation of pregnancy. The increasing use of obstetric ultrasound has also raised many ethical challenges, especially in relation to its non-medical use, but the ethical discussions and research in this area are still limited. The overall aim of this project is to explore midwives' and obstetricians' views and experiences on the use of obstetric ultrasound in relation to clinical management and care, and maternal and fetal roles and rights, in low-income and high-income countries. The project commenced in 2012, and the participating countries are Australia, Norway, Sweden, Rwanda, Tanzania and Vietnam. Qualitative data collection has been completed in five of the six countries via focus group discussions with midwives and individual interviews with obstetricians. Data are analysed using qualitative content analysis.

Kristina Edvardsson, international project coordinator, is supported by a 3-year international Postdoctoral Fellowship from the Swedish Research Council for Health, Working Life and Welfare (FORTE). The project received further funding (Ingrid Mogren) from the Swedish Research Council of approximately 370 000 AUD over 4 years. The project is subject to further applications for funding of a doctoral student position.

FUNDING: Umeå University, Sweden, Swedish Research Council, Swedish Research Council for Health, Working Life and Welfare (FORTE)

STATUS: One paper published, one submitted, three in manuscript form; four conference abstracts accepted; further data analysis and reporting ongoing

Edvardsson K, Small R, Persson M, Lalos A, Mogren I. 'Ultrasound is an invaluable third eye, but it can't see everything': a qualitative study with obstetricians in Australia. BMC Pregnancy Childbirth 2014; 14:363

Edvardsson K, Small R, Lalos A, Persson M, Mogren I. Ultrasound's 'window on the womb' brings ethical challenges for balancing maternal and fetal health interests: obstetricians' experiences in Australia. BMC Med Ethics 2015; 16:31.

Evaluation of the PANDA national perinatal depression helpline

Helen McLachlan, Della Forster, Rhonda Small, Touran Shafiei, Laura Biggs

In January 2013, Judith Lumley Centre was engaged by PANDA to undertake an independent evaluation of the PANDA National Perinatal Depression Helpline.

The evaluation comprised a number of components including a description of the PANDA caller profile, demand and referral pathways, using routinely collected data; an exploration of the views and experiences of callers to PANDA via an online survey, a hard copy survey or a telephone interview. It also included key informant consultations with PANDA volunteers, PANDA counsellors and key stakeholders via online surveys, focus groups and face-to-face interviews.


STATUS: Report completed; papers in preparation

PUBLICATION: Shafiei T, Forster D, McLachlan H, Small R, Biggs L. Evaluation of the PANDA National Perinatal Depression Helpline. Melbourne, Australia: Judith Lumley Centre, La Trobe University; January 2014

Obstetric outcomes for immigrant women

Rhonda Small, Mary-Ann Davey, Fetene Berhanu Belihu, in collaboration with the Victorian Perinatal Data Collection Unit and Paul Agius, Burnet Institute

This project continues 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 (suggesting possible cause for concern about the role of communication difficulties in decision-making during labour and birth in these poorer outcomes); and consistently poorer ratings of maternity care by immigrant women from NES-countries. Analyses investigating mode of birth outcomes for Vietnamese-born women over time (1984-2007) have been completed with findings presented at two conferences; and a paper is being finalised for submission early in 2015. A further project utilising these VPDC data was commenced in July 2014 by Doctor of Public Health candidate, Fetene Belihu. He is investigating outcomes for East African born women and their infants, supervised by Rhonda Small and Mary-Ann Davey.


STATUS: Vietnamese outcomes paper drafted; East African project ethics approval obtained; data analysis commenced

Risk factors and trends in postpartum haemorrhage (PPH) in Victoria 2003-2011: health policy implications

Mary-Ann Davey, Maggie Flood, Susan McDonald; Wendy Pollock; Fiona Cullinane, Royal Women's Hospital

This study analyses trends in postpartum haemorrhage (PPH) and associated morbidities using data from the Perinatal Data Collection for all births in Victoria, 2003-2011. The frequency and severity of postpartum haemorrhage are increasing, as are rates of known risk factors. Small increases in rates of postpartum haemorrhage - a continuing major cause of maternal morbidity - may impact heavily on women and their families. This study will provide up‐to‐date local information on postpartum haemorrhage incidence and risk factors, enabling insights into strategies to reduce these and to inform policy and practice in maternity services to benefit the women of Victoria.


STATUS: analysis in the early stages

Collaborative work

Fetal lactate measurement to reduce caesarean sections during labour: a randomised trial (FLAMINGO)

Christine East and Shaun Brennecke, Royal Women's Hospital; Mary-Ann Davey; Omar Kamlin, Royal Women's Hospital

There is currently an epidemic of caesarean sections performed in Australia and overseas. Although many caesarean sections are performed for concerns about fetal welfare, the majority of babies are shown to be well at birth, meaning that the operation, with its inherent short‐ and long-term risks, could have been avoided, without compromising the baby's health. In this study, half the babies with a non‐reassuring heart rate recording during labour will have a blood test to measure lactate and the other half will not. We will then determine whether having a lactate test makes a difference in the number of women having caesarean births.

FUNDING: NHMRC Project Grant 2012-2015, University of Melbourne

STATUS: recruitment underway

Impact of risk-reducing bilateral salpingo-oophorectomy on non-cancer outcomes in young high-risk women: a multicentre prospective study (WHAM)

Martha Hickey, Royal Women's Hospital; Gillian Mitchell, Peter MacCallum Cancer Centre; Bettina Meiser, University of New South Wales; John Wark, Royal Melbourne Hospital; Mary-Ann Davey

This study is looking at menopause symptoms, sexual function, bone health and risk factors for cardiovascular disease in women who choose to have surgery to remove their ovaries and fallopian tubes because they are considered high risk for developing ovarian cancer. They will be asked to invite an age‐matched friend to take part in the study as part of the "low risk" control group.

FUNDING: NHMRC Project Grant 2013-2015, University of Melbourne

STATUS: recruitment underway

Pregnancy-related complications in Rwanda: prevalence, associated risk factors and health economic impact, and maternal experience

Jean Paul Semasaka Sengoma, University of Rwanda, Ingrid Mogren, Umeå University, Sweden, Gunilla Krantz, University of Gothenburg, Sweden, Cyprien Munyanshongore and Manasse Nzayirambaho, University of Rwanda, Kristina Edvardsson, Judith Lumley Centre/ Umeå University, Sweden

Since 2013, the Swedish International Development Cooperation Agency (SIDA) has been supporting a large research project on maternal health care in Rwanda. The project includes four PhD projects with the common aim of investigating various aspects of Rwanda's antenatal care and delivery services. This includes quality and utilisation of antenatal care and delivery services, pregnancy complications and their impact on health and family circumstances, with analyses of cost effectiveness. Rwanda is a low-income country, with approximately 61% of the 11,000,000-person population classified as poor. The maternal mortality has been estimated to be 476 per 100,000 live births, and the prevalence and impact of obstetric complications are largely unknown.

As part of his PhD, Dr Jean Paul Semasaka is focusing on determining the prevalence of pregnancy-related complications, their associated risk factors and their consequences to the woman and her family. The thesis will include population-based as well as health-facility based studies in combination with a qualitative study involving women who have experienced pregnancy-related complications.

STATUS: Population-based and facility based data collection completed; data preparation and analyses ongoing

FUNDING: the Swedish International Development Cooperation Agency (SIDA)

Reproductive Outcomes And Migration (ROAM): an international collaboration

Rhonda Small, Mary-Ann Davey and Touran Shafiei; ROAM Steering Group: Rhonda Small; Anita Gagnon, McGill University, Canada; Mika Gissler, Institute of Health, Finland; Carolyn Roth, University of Keele, UK; Jennifer Zeitlin, INSERM, France and EURO‐PERISTAT

The collaboration aims to undertake comparative work on 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 to establish research links between Canada and Australia for comparing reproductive health outcomes of immigrant and refugee women. The first meeting of a wider collaborative network with researchers from the UK, Italy, France, Belgium, and Finland was held at the European Congress of Epidemiology in Porto, Portugal in September 2004. Since then collaborators from a range of other countries have joined the collaborative network and annual meetings have been held.

ROAM collaborators met in Granada, Spain 12-13 April 2014, following the European Public Health Association Migrant Health Conference. Completed work was presented and further collaborative research was discussed. Projects with involvement from the Judith Lumley Centre include:

  • A cross-country comparative study of migration and severe maternal morbidity (two papers published)
  • Migrant friendly maternity care questionnaire project (paper published, further translation and piloting underway)
  • Migrant women's experiences of maternity care: a systematic and comparative review  (paper published)

FUNDING: Canadian Institutes of Health Research International Collaboration grant 2007-2008 and Systematic Review grant 2010

STATUS: fourteen papers published; five submitted; several in preparation

Urquia ML, Glazier RH, Mortensen L, Nybo-Andersen A-M, Small R, Davey M-A, Rööst M, Essén B, for the ROAM (Reproductive Outcomes and Migration. An International Collaboration). Severe maternal morbidity associated with maternal birthplace in three high-immigration settings. Eur J Public Health 2015 (in press). Epub 2015 Jan 13

Gagnon AJ, Small R, Sarasua I, Lang C. Measuring perinatal health equity and migration indicators for international comparisons. Health Care Women Int 2015; 36(6):684-710

Gagnon A, DeBruyn R, Essen B, Gissler M, Heaman M, Jeambey Z, Korfker D, McCourt C, Roth C, Zeitlin J, Small R, for the ROAM Collaboration. Development of the Migrant Friendly Maternity Care Questionnaire (MFMCQ) for migrants to Western societies: an international Delphi consensus process. BMC Pregnancy Childbirth 2014; 14:200

Urquia ML, Glazier RH, Gagnon AJ, Mortensen LH, Nybo Andersen AM, Janevic T, Guendelman S, Thornton D, Bolumar F, Río Sánchez I, Small R, Davey MA, Hjern A, for the Roam Collaboration. Disparities in pre-eclampsia and eclampsia among immigrant women giving birth in six industrialised countries. BJOG 2014; 121(12):1492-500

Merry L, Small R, Blondel B, Gagnon A. International migration and caesarean birth: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2013; 13: 27

Gagnon AJ, McDermott S, Rigol-Chachamovich J, Bandyopadhyay M, Stray-Pedersen B, Stewart D, for the ROAM Collaboration. International migration and gestational diabetes mellitus: a systematic review of the literature and meta-analysis. Paediatr Perinat Epidemiol 2011;25(6):575-92

Gissler M, Alexander S, Macfarlane A, Small R, Stray-Pedersen B, Zeitlin J, Zimbeck M, Gagnon A, For The Roam C. Stillbirths and infant deaths among migrants in industrialized countries. Acta Obstet Gynecol Scand 2009;88(2):134-48

Gagnon AJ, Zimbeck M, Zeitlin J, The ROAM Collaboration. Migration to western industrialised countries and perinatal health: A systematic review. Soc Sci Med 2009;69(6):934-46

Small R, Gagnon A, Gissler M, Zeitlin J, Bennis M, Glazier RH, Haelterman E, Martens G, McDermott S, Urquia M, Vangen S. Somali women and their pregnancy outcomes postmigration: Data from six receiving countries. BJOG 2008;115(13):1630-40

Gagnon A, Ruppenthal L, Merry L, Small R, Ogilvie L, Liegl B, Schindlauer D, Frideres J, Akbari A, Reichhold S, Mårtenson H. Conceptual clarity in international collaborations: A point of departure for policy-relevant research on discrimination. JIMI 2004;5(4):477-94

ROAM website