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Aims: To understand why some nursing homes use hospital avoidance programs more frequently than others. Design: Two hospital avoidance programs, called residential-in-reach services in Victoria, Australia, were evaluated using a qualitative descriptive design. Methods: Between 2014 and 2018, 127 semi-structured interviews were conducted with staff from nursing homes, general practitioners and staff from the residential-in reach services. The interviews took an average of 45 min and transcripts were thematically analysed. Results: Nursing home reliance on residential-in-reach services to manage deteriorating residents was evident in both evaluations. Irrespective of the model of service provision, reliance was associated with: the increased care needs of residents; difficulties accessing timely and appropriate medical care; and the reduced numbers of skilled registered nurses to assess and manage deteriorating residents. Conclusion: The residential-in-reach services are highly regarded by nursing homes. However, some are reliant on these services to provide nursing assessment and management. Using residential-in-reach services to substitute for nursing care, deskills nurses and shifts the cost of providing care from the service provider to other agencies. To provide residents with quality nursing care, the number of skilled registered nurses able to work within their scope of practice needs to be increased in Australian nursing homes. Impact: The findings highlight the challenges of providing care in older people living in aged care. Increasing the number of skilled registered nurses in Australian nursing homes, would support deteriorating residents to stay in familiar surroundings and reduce reliance on external services to provide nursing care.

Objective: To identify factors that health and allied health practitioners consider central to excellence in residential aged care facilities (RACFs) with the objective of supporting improvements in monitoring, accountability and service delivery within the sector. Methods: In a qualitative, exploratory designed study, interviews were undertaken with seventeen participants from 10 health and allied health disciplines (general practice, dentistry, pharmacy, psychiatry, psychology, neuropsychology, physiotherapy, speech pathology, occupational therapy and palliative care) with experience of working in Victorian RACFs. The interviews focused on how practitioners perceived excellence within RACFs. Data were analysed thematically. Results: Thematic analysis yielded five themes, which correspond with different dimensions or ways of understanding excellence, including resident well-being, residences as a true home, good practice models, effective management and skilled staff, and unmet needs. Under each of these themes, participants referred to issues closely related to the concerns of their particular professions as well as those more general in nature. Conclusions: The diversity in issues to which participants drew attention highlights the importance of obtaining the perspectives of a broad range of practitioners providing services to RACF residents to achieving excellence in the sector. Commonalities in their responses indicate the potential for a greater level of collaboration among the health and allied health professions.

Despite the prevalence of mental health concerns among those who live in residential aged care, many residential aged care facilities (RACFs) provide little by way of psychological support. Drawing on qualitative data obtained from interviews with residents from across 15 RACFs in Victoria, Australia, this article adds to understandings about the diversity and impact of mental health challenges experienced by residents, and gaps in the knowledge of staff about how to address such. Thus, it also offers evidence of the urgent need for RACFs to provide residents both better access to specialist mental health practitioners and training to care staff on mental health issues.

Background: Meeting the complex health needs of an increasing number of older people is a critical workforce challenge for the Australian health and aged care sectors. Nurses are the largest group of registered health care professionals and fundamental to delivering health and aged care in Australia. However, while nursing students encounter increasing numbers of older people in all health and aged care settings, little is known about how they are educationally prepared to care for them. Aim: To investigate the curriculum content and method of teaching the care of older people in Australian Bachelor of Nursing degrees. Methods: A population sample of all Australian nursing schools offering Bachelor of Nursing degrees. Nurse academics involved in subject coordination or curriculum development were recruited. A telephone-assisted survey explored ‘the care of older people’ in Australian undergraduate nursing curricula. Descriptive statistical analyses were undertaken. Results: The response rate was 100%. Curricula were acute care focused with content specific to the care of older people scaffolded across curricula. A variety of teaching and learning methods were reported. Clinical experiences with older people occurred in residential aged care settings, generally in the first year of the degree. Conclusions: Preparation of pre-registration nurses for the care of older people requires improvement in curricula content and clinical experience to equip graduates to provide safe, person-centred care that meets the needs of older Australians.

In Australia, the majority of people with dementia live in the community with informal care provided by family, commonly a spouse. A diagnosis of dementia is a threat to one’s personhood and is often accompanied by perceptions of future dependency, which will involve the inability to carry out conventional roles and complete everyday tasks including making decisions. Being able to make decisions, however, is part of being a ‘person’ and it is through relationships that personhood is defined and constructed. In face-to-face interviews with seven couples (a carer and person with dementia dyad) and two spouse carers, this study explored why, and how, spouse carers support continued involvement in decision-making for people with dementia. The findings highlight the importance of loving and respectful relationships in the development of strategies to support continued decision-making for people with dementia.

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Objective To investigate decision-making around hospital transfer and/or referral of residents to a Residential InReach (RiR) service in north-eastern metropolitan Melbourne, Australia, from the perspectives of residential aged care facility (RACF) staff, general practitioners (GPs) and RiR registered nurses (RNs). Methods Thirty-one staff from eight RACFs, five GPs and four RiR RNs participated in individual or group interviews. Results Residential aged care facility staff and GPs valued and relied upon RiR to manage unwell residents. Thematic analysis identified RiR utilisation was driven by the following: (i) complexity of decision-making processes in RACFs; (ii) variability in facility-based medical and nursing care; and (iii) impact of RiR service outcomes on patients and referrers. Conclusion Availability of timely and appropriate medical and nursing care in RACFs was reported to influence transfers to the hospital and/or referrals to RiR. RiR was used to complement or substitute usual care available to residents. Further research and improvements in RACF and RiR resources are required.

Objective To report on the conceptualisation of a model for residential aged care in Australia. Methods Three-stage approach involving initial model conceptualisation; extensive consultation with stakeholders to test and develop the model for feasibility and acceptability; and examination of whether the model addresses circumstances that arise in scenarios of organisational failure. Results A model consisting of five domains relevant to the experience of older adults living in residential aged care-health care; social inclusion; rights; personal care and re-ablement; and dementia management. Conclusions This proposed model of residential aged care takes as its purpose the provision of person-centred care to older people with complex health issues, requiring end-of-life care, and/or living with dementia. This includes supporting dignity of risk and quality of life and enabling older adults to thrive.

Older people living in the community use complementary medicine (CM) to manage the symptoms of chronic illness; however, little is known about CM use by older people living in care settings. Using focus groups and individual interviews, this study explored the use of CM from the perspective of 71 residents, families, and health professionals from six residential aged-care facilities in Victoria, Australia. Residents used CM to manage pain and improve mobility, often covertly, and only with the financial assistance of their families. Facility policies and funding restrictions constrained CM use at the individual and facility level. An absence of evidence to support safety and efficacy coupled with the risk of interactions made doctors wary of CM use in older people. These findings have relevance for the large number of CM using “baby-boomers” as they move into residential aged-care.

Objectives: To ascertain the research priorities of staff working in Victorian residential aged care services (RACS). Method: In October 2016, all 754 Victorian RACS were asked to list three most important research priorities in a confidential postal survey. Descriptive statistics and content analysis were used to analyse the data. Results: One hundred and sixty-two (21.5%) RACS participated. Research priorities, in order of importance, were grouped thematically as workforce issues, strategies to manage residents with dementia and funding to the sector. Staffing numbers and mix, particularly nurse-to-resident ratios, dominated workforce issues. The management of responsive behaviours was highlighted as a pressing clinical issue, and insufficient funding to the sector impacted on most issues reported. Conclusions: The research priorities identified were inter-related. Some were already well researched, suggesting RACS staff have little time and/or limited access to research evidence to inform the care and management of residents, possibly because of inadequate staffing and funding.

As the Australian population ages the demand for nursing care which focuses on responding to the needs of the older person will increase. Few newly graduated Registered Nurses (RNs) currently enter the aged care workforce and few select a career in caring for older people; yet older people are the largest patient group in most health care environments. This research, conducted by the Australian Hartford Consortium of Gerontological Nursing Excellence (Aus-HCGNE), explored how care of the older person is currently taught in Australian schools of nursing (SoN). The interview guide included questions about: whether care of the older person is taught in separate subjects or integrated across the curriculum; academics’ qualifications; subject content; and aged care clinical placements. The head of each of the 33 Australian schools of nursing was contacted, invited to participate and asked to nominate the appropriate academics (undergraduate/curriculum co-ordinators) who would be the most appropriate person to participate in the interview. These academics were then contacted, written informed consent was obtained, interviews were scheduled and completed. This research is timely given the current Royal Commission into Aged Care Quality and Safety in Australia, one focus of which is nurses in residential aged care in respect to numbers, education and competence. This research will be completed by mid-2019. The results will be fed back to SoN to inform the development of their curricula and the preparation of future RNs who will undoubtably need to be expert in the care of older people across the health sector.

Objective to provide an accessible list of individual and population-based risk factors associated with very preterm birth to assist care providers in planning appropriate pregnancy care. Design a population-based case-control study. Setting Victoria, Australia. Participants women were recruited from April 2002 to 2004. Cases had a singleton birth between 20 and 31+6 weeks gestation and controls were a random selection of women having a birth of at least 37 weeks gestation in the same time period as the cases. Measurements and findings structured interviews were conducted within a few weeks postpartum with 603 cases and 796 controls. Data were collected on sociodemographic factors; obstetric and gynaecological history; and maternal health problems, both pre-existing and occurring during the index pregnancy. Risk factors were calculated. Key conclusions when correlated, risk factors were grouped as either lifestyle or maternal health factors. The majority of the risks were obstetric or gynaecological factors. Risks occurring in pregnancy may precipitate preterm birth. Implications for practice knowing the risk factors for very preterm birth is likely to be helpful for pregnancy care providers. The development of a risk factor checklist based on the findings presented here may enable more informed planning of care and timely intervention.

Objectives: There is increasing evidence of the use of complementary and alternative medicine (CAM) by older people living in the community; however, little is known about the use of CAM in residential aged-care facilities (RACF). This review examined the literature on the use of CAM in RACF, focusing on prevalence, motivations, and support for use. Methods: A search of multiple databases between 2000 and 2010 was conducted. Articles were analyzed under five key themes: prevalence of CAM use, CAM user profile, motivations for use, expectations for and satisfaction with CAM use, and institutional and/or staff support for CAM use. Results: Only five articles were found that met the inclusion criteria. The review highlights the absence of evidence regarding the use of CAM by older people in RACF. Conclusions: To inform policy and improve clinical practice in line with the aging of the population, nationally representative, population-based studies are required.

Objective To investigate the relation of prior intracervical procedures with very preterm birth. Design A population-based case-control study. Setting The study was conducted in Australia between 2002 and 2004. Sample Three hundred and forty-five women having a medically indicated and 236 having a spontaneous singleton birth between 20 and 31 weeks of gestation and 796 women selected randomly from all those giving birth at ≥37 weeks of gestation. Methods Interview data were analysed using logistic regression. Main outcome measure Very preterm birth. Results Very preterm birth was significantly associated with having any intracervical procedure [adjusted odds ratio (AOR) 2.07; 95% confidence interval (CI) 1.6-2.7], in particular curettage associated with abortion (AOR 1.80; 95% CI 1.2-2.6). Assisted reproductive technology procedures were significantly associated with medically indicated very preterm birth (AOR 3.07; 95% CI 1.8-5.3) and treatments for precancerous cervical changes were significantly associated with spontaneous very preterm birth, as follows: conization/cone biopsy (AOR 3.33; 95% CI 1.8-6.2) and cauterization/ablation (AOR 2.27; 95% CI 1.4-3.8). Suction aspiration for abortion, abnormal Pap smear without treatment and abortion without instrumentation were not associated with very preterm birth. Conclusions Intracervical procedures are associated with very preterm birth. Notably, curettage rather than any other procedure associated with abortion appears to be implicated in the risk. The introduction of infection during cervical procedures may be the common link with risks found. Changing clinical practice in the management of abortion and human papillomavirus vaccination may lead to lowering the risks of very preterm birth.

Endocrine research in the 1930s increased and extended the use of sex hormones as medical therapies in an unprecedented way, especially for female ailments. In the 1950s the therapeutic use of sex hormones extended to the treatment of ‘tall’ girls. Ambiguity in the definition of the ‘tall’ girl, the arbitrary nature of the treatment decision, and diversity in the therapeutic regimes highlight the problematic nature of this medical practice. Using linguistic repertoires to study the political and ideological implications found in the patterned use of language, this paper reports on a discourse analysis of the medical literature on treatment of tall girls between the 1950s and 1990s, when this treatment was at its peak. Three linguistic repertoires emerged: the institutional authority of medicine to determine the ‘abnormality’ of tall stature in females; the clinical knowledge and experience in the diagnosis of medical risk associated with tall stature in women; and using hormones as cosmetic therapy to (re)produce femininity in tall girls. All three related to the maintenance of the cultural representations and social expectations of femininity. With no evidence of psychological harm associated with tall stature in women, and no long-term studies of either effectiveness or benefit, over five decades clinicians persuaded themselves and their patients that tall stature required therapeutic intervention. The treatment of tall girls with high dose oestrogen must be viewed as the medicalisation of a normal physical attribute adversely related to the social construction of gender.

The prevalence and intractability of preterm birth is known as is its association with reproductive history, but the relationship with sequence of pregnancies is not well studied. The data were from a population-based case-control study, conducted in Victoria, Australia. The study recruited women giving birth between April 2002 and April 2004 from 73 maternity hospitals. Detailed reproductive histories were collected by interview a few weeks after the birth. The cases were 603 women having a singleton birth between 20 and

In published studies of preterm birth, analyses have usually been centred on individual reproductive events and do not account for the joint distributions of these events. In particular, spontaneous and induced abortions have often been studied separately and have been variously reported as having no increased risk, increased risk or different risks for subsequent preterm birth. In order to address this inconsistency, we categorised women into mutually exclusive groups according to their reproductive history, and explored the range of risks associated with different reproductive histories and assessed similarities of risks between different pregnancy histories. The data were from a population-based case-control study, conducted in Victoria, Australia. The study recruited women giving birth between April 2002 and April 2004 from 73 maternity hospitals. Detailed reproductive histories were collected by interview a few weeks after the birth. The cases were 603 women who had had a singleton birth between 20 and less than 32 weeks gestation (very preterm births including terminations of pregnancy) and the controls were 796 randomly selected women from the population who had had a singleton birth of at least 37 completed weeks gestation. All birth outcomes were included. Unconditional logistic regression was used to assess the association of very preterm birth with type and number of prior abortions, prior preterm births and sociodemographic factors. Using the complex combinations of prior pregnancy experiences of women (including nulligravidity), we showed that a history of prior childbirth (at term) with no preterm births gave the lowest risk of very preterm birth. With this group as the reference category, odds ratios of more than two were associated with all other prior reproductive histories. There was no evidence of difference in risk between types of abortion (i.e. spontaneous or induced) although the risk increased if a prior preterm birth had also occurred. There was an increasing risk of very preterm birth associated with increasing numbers of abortions. This method of data analysis reveals consistent and similar risks for very preterm birth following spontaneous or induced abortions. The findings point to the need to explore commonalities rather than differences in regard to the impact of abortion on subsequent births.

Objective to describe the structure and organisation of hospital postnatal care in Victoria, Australia. Design postal survey sent to all public hospitals in Victoria ( n = 71 ) and key-informant interviews with midwives and medical practitioners ( n = 38 ). Setting Victoria, Australia. Participants providers of postnatal care in Victorian public hospitals. Findings there is significant diversity across Victoria in the way postnatal units are structured and organised and in the way care is provided. There are differences in numerous practices, including maternal and neonatal observations and the length of time women spend in hospital after giving birth. Although the benefits of continuity of care are recognised by health care providers, continuity is difficult to provide in the postnatal period. Postnatal care is provided in busy, sometimes chaotic environments, with many barriers to providing effective care and few opportunities for women to rest and recover after childbirth. The findings in this study can, in part, be explained by the lack of evidence that has been available to guide early postnatal care. Key conclusions and implications for practice current structures such as standard postnatal documentation (clinical pathways) and fixed length of stay, may inhibit rather than support individualised care for women after childbirth. There is a need to move towards greater flexibility in providing of early postnatal care, including alternative models of service delivery; choice and flexibility in the length of stay after birth; a focus on the individual with far less emphasis on care being structured around organisational requirements; and building an evidence base to guide care.

Objective to describe midwives' views and experiences of the provision and organisation of hospital-based postnatal care. Design s emi-structured interviews with key informants who provide hospital-based postnatal care. Setting public hospitals in Victoria, Australia. Participants clinical midwives and midwifery managers ( n =33). Findings midwives remain positive about working in hospital-based postnatal care; however, their satisfaction is influenced by barriers to effective care beyond their control, which specifically limit the time available to spend with women. They described many constraints on their practice, including the length of hospital stay, inadequate midwife-to-woman ratios, the busyness of postnatal units, and the effect of visitors. Midwives viewed the aims of postnatal care to include education and support of women with breastfeeding and parenting skills, and helping in women's physical recovery after pregnancy and birth. Midwives' perceptions of the factors that influence women's satisfaction with postnatal care are consistent with what we know are women's views: continuity of care, individualised unrushed care, and flexibility in routine practices. Key conclusions and implications for practice midwives' views and experiences of hospital-based postnatal care are in accordance with women's views and experiences. They are less than satisfied with hospital-based postnatal care, and they perceive a need for individualised, unrushed, flexible care. With evidence from both providers and women about the unsatisfactory nature of the current provision and organisation of hospital-based postnatal care, new approaches to this episode of care need to be explored.

Snoezelen has become an increasingly popular therapy in residential aged care facilities in Australia and elsewhere, despite no conclusive evidence of its clinical efficacy. This paper reports on an evaluation of the use of Snoezelen compared to ‘common best practice’ for allaying the dementia related behaviors of wandering and restlessness in two residential aged care facilities in Victoria, Australia. Sixteen residents had their behavior and responses to Snoezelen or ‘common best practice’ observed and recorded over three time periods. The Wilcoxon signed-rank test showed there was a significant improvement in behaviors immediately after the intervention and after 60 min. However, no significant differences were found between residents receiving Snoezelen and ‘common best practice’ interventions for the reduction of the dementia related behaviors.

Social norms powerfully shape what is viewed as acceptable throughout various life-stages and the transition to parenthood has long been a powerful collective cultural symbol, providing a gendered identity and normalcy status central to adult roles (McQuillan et al., 2012; Dykstra & Hagestad, 2007). In contemporary Australia, where the socio-political milieu encourages fertility and promotes the family (Rich, Taket, Graham & Shelley, 2011; Gray, Qu & Weston, 2008), achieving parenthood is a social norm expected of both men and women. For women in particular, gender identity is linked to becoming a mother (Loftus & Androit, 2012; Thompson, 2005; Letherby, 2002). Female gender identity is defined and performed through socially prescribed concepts of femininity that govern bodily attributes and behaviours, which include expectations of motherhood (Van Den Wijngaard, 1997; Moi, 1989). The desire to have children remains high among the majority of Australian men and women across all ages (Holton, Fisher & Rowe, 2011; Thompson & Lee, 2011; Holden et al., 2005; Weston, Qu, Parker & Alexander, 2004) despite the growing tendency to delay childbearing. Survey research consistently indicates that most Australians want to have children and that many have fewer children than they would like (Holton et al., 2011). Longitudinal studies reveal that fertility expectations are dynamic and attribute relationship status as a major factor in future expectations about childbearing (Mitchell & Gray, 2007). While relationship factors appear to be the most important, other considerations such as economic security and career path planning are also important, particularly in decisions about when to have children. Over the past 20-30 years, men and women are spending an ever longer part of their young adult years in their parental home and education and are delaying their entry into the labour market, union formation and thus parenthood (Weston et al., 2004). This trend is found in other industrialised countries (Beaujot, 2004). There is also an expectation that, because there is now the capacity to decide when not to have children using contraception (Keogh, 2006), the decision to have (and when to have) children is also able to be controlled. However, the intersection between age andThe nexus between the social and the medicalfertility remains an important one and, while the desire to have children remains high, the capacity to have children is compromised by choosing to do so at an older age. This increasing trend to shift childbearing to later age among Australians (Macaldowie, Wang, Chambers & Sullivan, 2012) has resulted in increased use of infertility treatments to achieve parenthood. The proliferation of assisted reproductive technologies (ART) to diagnose and treat infertility has transformed childlessness from a social process into a medical problem, shifting normative expectations of the reproductive body and entrenching social norms and expectations (Loftus, 2009; Franklin, 1997; Greil, 1991). International evidence suggests the experience of infertility is also gendered (Thompson, 2005; Carmeli & Birenbaum-Carmeli, 1994; Nachtigall, Becker & Wozny, 1992) and that the burden of treatment falls to women irrespective of reason for infertility (Loftus, 2009; Schmidt, 2006). Such is the powerful status associated with parenthood, and motherhood in particular, that failure to attain this social norm can still invoke stigma and blame, for example, for past behaviours that may have contributed to infertility, or by not persevering sufficiently with all the options available, generally meaning ART (Allen & Wiles, 2013; Rich et al., 2011). In fact, it has been argued that the proliferation of medical infertility interventions may have contributed to the strength of the social norms about parenting; where previously ambivalence towards motherhood may have been more socially acceptable (Greil, Slauson-Blevin & McQuillan, 2011).

Introduction A holistic approach to medical care is a key component of integrative medical practice. As an alternative to biomedical emphasis on illness and disease, integrative medical practice focuses on wellness. Principles of vitalism and humanism inform complementary and alternative medicine (CAM) approaches to health and healing, thus integrative medical practitioners have capacity to extend ideas of healing from the individual biology to broader public health trends and concerns. Methodology and approach We report on qualitative semi-structured interviews with 23 integrative medical doctors. Our research explored how they drew on CAM philosophical approaches to health and healing and how such approaches shaped their approach to practice. Results Integrative medical practitioners draw on CAM to understand causes of health problems, approaches to healing, and the role of the individual in healing. The key tenets of the philosophical approach identified by doctors were holism, vitalism, and empowerment. These notions inform their health practice. They focus on helping patients to become actively engaged in their health, in particular, in lifestyle change. These doctors see their practice as distinctly different from biomedicine, seeing biomedicine as too limited to in its approach. Conclusions While the principles underpinning CAM may open up opportunities for integrative medical practitioners to take a public health stance in their work, this approach is limited. Integrative practitioners see their approach as different to their biomedical peers, but their capacity to re-orient health from cure to prevention is often limited to notions of lifestyle advice and individual responsibility for health and healing.

Introduction Increasing numbers of general medical practitioners in Australia define themselves as integrative practitioners, incorporating both allopathic and complementary and alternative medicine (CAM) in an environment where evidence-based medicine is the hallmark of best practice in medicine. Methodology and approach We conducted semi-structured qualitative interviews with 23 self-identified integrative medical practitioners in two states of Australia. Participants were recruited from publicly available lists of self-identified integrative medical practitioners – the local telephone listing and the website of their professional organisation. Interviews explored how doctors define and use evidence in their practice. We undertook a thematic analysis of the interview transcripts with particular exploration of the key ideas that emerged about their use of evidence. Results These practitioners are sceptical about the dominance of the evidence-based medicine movement, and push to reclaim their autonomy based on the indeterminancy of individual cases. They acknowledge that an understanding of clinical benefit may not be scientifically evidenced and utilise discourses of experience and safety in discussing their clinical practice. Conclusions Our findings provide further insights into how medical practitioners work within their own profession, their relationships with other care providers (specifically CAM practitioners), their views about their non-integrative medical peers and their resistance to prescribed ways of clinical practice.

Aims and objectives To describe the use of multi-sensory interventions in residential aged care services (RACS) for the management of dementia-related behaviours in residential aged care in Victoria, Australia. Background The popularity of multi-sensory interventions has spread worldwide, including for use in residential aged care, despite limited evidence to support their efficacy. Design This study reports the findings of the first stage of a two-stage project that was undertaken to describe and evaluate the use of multi-sensory interventions for the management of dementia-related behaviours in all residential aged care facilities in Victoria, Australia. Methods A computer-assisted telephone interview survey was developed and administered to residential aged care facilities in Victoria, Australia, to collect descriptive data on the use of multi-sensory interventions for the management of dementia-related behaviours. Results A diverse and eclectic range of multi-sensory interventions are currently being used by residential aged care facilities. The findings suggest the use of multi-sensory interventions are used in an ad hoc manner, and there is no universal definition of multi-sensory interventions, little formal training for staff administering the interventions and no guideline for their use, nor evaluation of their impact on residents' behaviour. Conclusion Multi-sensory interventions have been widely adopted for use in RACS in Victoria, Australia, and are currently being used without formal guidelines and little evidence to support their use in clinical practice. Relevance to clinical practice In the absence of a formal definition of what constitutes a multi-sensory intervention, training for staff and careful assessment and monitoring of residents who receive multi-sensory interventions, we recommend further research and development of policy and procedures to safe guard the use of multi-sensory interventions for people with dementia.

Objective in Australia, as in other developed countries, women have consistently reported lower levels of satisfaction with postnatal care compared with antenatal and intrapartum care. However, in Victoria Australia, women who receive private hospital postnatal care have rated their care more favourably than women who received public hospital care. This study aimed to gain a further understanding of this by exploring care providers’ views and experiences of postnatal care in private hospitals. Design qualitative design using semi-structured interviews and thematic analysis. Setting private maternity hospitals in Victoria, Australia. Participants eleven health-care providers from three metropolitan and one regional private hospital including eight midwives (two maternity unit managers and six clinical midwives) and three obstetricians. Findings two global themes were identified: ‘Constrained Care’ and ‘Consumer Care’. ‘Constrained care’ demonstrates the complexity of the provision of postnatal care and encompasses midwives’ feelings of frustration with the provision of postnatal care in a busy environment complicated by staffing difficulties, a lack of continuity and the impact of key players in postnatal care (including visitors, management and obstetricians). ‘Consumer care’ describes care providers’ views that women often approach private postnatal care as a consumer, which can impact on their expectations and satisfaction with postnatal care. Despite these challenges, care providers, particularly midwives, highly valued (and generally enjoyed working in) postnatal care. Key conclusions this study, along with other Australian and international studies, has identified that hospital postnatal care is complex and characterised by multiple barriers which impact on the provision of quality postnatal care. Further research is needed to evaluate routine postnatal practices and continuity of care within the postnatal period. In-depth qualitative studies investigating women's expectations and experiences of postnatal care in both the public and private sector are also needed.

Australian women of reproductive age are frequent users of complementary and alternative medicine (CAM), consulting practitioners and self-medicating with over-thecounter and Internet-derived supplements.However, there are gaps in knowledge about the use of CAM for fertility enhancement.6–8 We undertook a retrospective audit of all new clients attending a CAM practice in Melbourne, Australia during September 2008. The practice specializes in fertility enhancement, offering an array of modalities. The audit aimed to describe new clients seeking fertility advice and to test the feasibility of recruiting research participants in this environment. Anonymous data abstracted from records included limited demographic information, reason for attending, the modality of practitioner consulted, and use of assisted reproductive technology (ART). A random sample of new clients was also invited to complete a simple anonymous survey indicating willingness to participate in research and to select their ideal recruitment method from a list of choices provided.

Hepatitis C virus was sought by nested polymerase chain reaction in the preoperative biopsy or the explanted liver of 100 consecutive adult patients undergoing orthotopic liver transplantation. In those found to be positive preoperatively, polymerase chain reaction was performed on subsequent biopsies. Of the 12 patients in whom HCV-RNA was identified in the liver by polymerase chain reaction preoperatively, viral recurrence was documented in ten of the 11 with posttrans-plant liver tissues available for study. In the one exception, hepatitis C virus was undetectable in the liver graft despite repeated co-amplification of albumin mRNA as an internal control, which may indicate viral clearance. In eight of the ten positive cases, HCV-RNA was also detectable in serum postoperatively, while HCV-RNA was undetectable in serum in both the cases in whom HCV-RNA was undetectable in tissue and in the patient who declined post-transplant biopsy. Two of the 12 patients infected with hepatitis C virus preoperatively have died during the follow-up period from causes unrelated to hepatitis C virus infection. While biochemical liver function in seven of those remaining has been excellent, histological evidence of at least mild chronic active hepatitis has been present in all ten cases for whom long-term biopsies are available. Three cases have progressed to severe, symptomatic chronic active hepatitis within 2 years of transplantation. Recurrent hepatitis C is associated with progressive liver disease and appreciable morbidity in a significant proportion of patients.

To investigate the relation of prior intracervical procedures with very preterm birth.A population-based case-control study.The study was conducted in Australia between 2002 and 2004.Three hundred and forty-five women having a medically indicated and 236 having a spontaneous singleton birth between 20 and 31 weeks of gestation and 796 women selected randomly from all those giving birth at ≥37 weeks of gestation.Interview data were analysed using logistic regression.Very preterm birth.Very preterm birth was significantly associated with having any intracervical procedure [adjusted odds ratio (AOR) 2.07; 95% confidence interval (CI) 1.6-2.7], in particular curettage associated with abortion (AOR 1.80; 95% CI 1.2-2.6). Assisted reproductive technology procedures were significantly associated with medically indicated very preterm birth (AOR 3.07; 95% CI 1.8-5.3) and treatments for precancerous cervical changes were significantly associated with spontaneous very preterm birth, as follows: conization/cone biopsy (AOR 3.33; 95% CI 1.8-6.2) and cauterization/ablation (AOR 2.27; 95% CI 1.4-3.8). Suction aspiration for abortion, abnormal Pap smear without treatment and abortion without instrumentation were not associated with very preterm birth.Intracervical procedures are associated with very preterm birth. Notably, curettage rather than any other procedure associated with abortion appears to be implicated in the risk. The introduction of infection during cervical procedures may be the common link with risks found. Changing clinical practice in the management of abortion and human papillomavirus vaccination may lead to lowering the risks of very preterm birth.

Identification of pregnancies that are higher risk than average is important to allow the possibility of interventions aimed at preventing adverse outcomes like preterm birth. Many scoring systems designed to classify the risk of a number of poor pregnancy outcomes (e.g. perinatal mortality, low birthweight, and preterm birth) have been developed, but they have usually been introduced without evaluation of their utility and validity.To determine whether the use of a risk-screening tool designed to predict preterm birth (in combination with appropriate consequent interventions) reduces the incidence of preterm birth and very preterm birth, and associated adverse outcomes.We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (December 2010), CENTRAL (The Cochrane Library 2010, Issue 4), MEDLINE (1966 to 17 December 2010), EMBASE (1974 to 17 December 2010), and CINAHL (1982 to 17 December 2010).All randomised or quasi-randomised (including cluster-randomised) or controlled clinical trials that compared the incidence of preterm birth between groups that used a risk scoring instrument to predict preterm birth with those who used an alternative instrument, or no instrument; or that compared the use of the same instrument at different gestations. The reports may have been published in peer reviewed or non-peer reviewed publications, or not published, and written in any language.All review authors planned to independently assess for inclusion all the potential studies we identified as a result of the search strategy. However, we identified no eligible studies.Extensive searching revealed no trials of the use of risk scoring systems to prevent preterm birth.The role of risk scoring systems in the prevention of preterm birth is unknown.There is a need for prospective studies that evaluate the use of a risk-screening tool designed to predict preterm birth (in combination with appropriate consequent interventions) to prevent preterm birth, including qualitative and/or quantitative evaluation of their impact on women's well-being. If these prove promising, they should be followed by an adequately powered, well-designed randomised controlled trial.

The use of complementary and alternative medicine (CAM) has increased in Western countries, with women identified as the primary users. Women's use of CAM in reproductive health is well documented; however, little is known about the use of CAM to enhance fertility, despite anecdotal evidence that this is a growing trend in reproductive medicine. The objective of this review was to examine the literature on women's use of CAM to enhance fertility, focusing on prevalence, motivations for use, and how information is sourced.A systematic search of multiple databases was conducted using key words and selection criteria.A total of eight articles that met the selection criteria, published between 1990 and 2010, were found and included in the review. The articles were analyzed under five key themes: "user prevalence," "user profile," "motivation for use," "expectations and satisfaction," and "referral and information sources." This review demonstrates important gaps in the evidence regarding women's use of CAM for fertility enhancement. There are no population-based studies with representative samples, no commonly accepted definitions of CAM research, and few studies describing women's motivations for and experiences of using CAM for fertility enhancement. Importantly, little is known about women's sources of information about CAM in this context.Nationally representative, population-based studies are required to fill the gaps in the evidence, provide prevalence rates, and inform policy and clinical practice.

Integrative medicine, a popular movement in the USA and Europe, is taught in many US medical schools. This study describes how Australian doctors define integrative medicine, what motivates them to work in integrative medicine and the incorporation of complementary and alternative medicines (CAM) into their practice.Semi-structured interviews were conducted between May and December 2009 with 23 doctors in two Australian states working in integrative medicine. A thematic analysis of interview transcripts was undertaken.Doctors' interpretations of the term 'integrative medicine' varied considerably. All maintained a strong belief in the usefulness of conventional medicine, while a holistic and patient-centred approach, promoting well-being, was central to their practice. Doctors' motivations for choosing an integrative approach to their practice of medicine also varied, but personal and professional experiences of alternative approaches to illness were influential in this decision. The nature of their clinical practice was also diverse; few doctors in this sample practice or professionally use CAM; a small number were happy to advise patients on the use of different modalities while even less referred to complementary practitioners.The concept and practice of integrative medicine among the doctors interviewed were diverse. This has implications for the Royal Australian College of General Practitioners inclusion criteria for the membership of their integrative medicine chapter. More broadly, the findings have implications for all medical practice and the education of medical students, as much of what integrative medicine doctors do may be considered simply as 'good medical practice'.

In published studies of preterm birth, analyses have usually been centred on individual reproductive events and do not account for the joint distributions of these events. In particular, spontaneous and induced abortions have often been studied separately and have been variously reported as having no increased risk, increased risk or different risks for subsequent preterm birth. In order to address this inconsistency, we categorised women into mutually exclusive groups according to their reproductive history, and explored the range of risks associated with different reproductive histories and assessed similarities of risks between different pregnancy histories. The data were from a population-based case-control study, conducted in Victoria, Australia. The study recruited women giving birth between April 2002 and April 2004 from 73 maternity hospitals. Detailed reproductive histories were collected by interview a few weeks after the birth. The cases were 603 women who had had a singleton birth between 20 and less than 32 weeks gestation (very preterm births including terminations of pregnancy) and the controls were 796 randomly selected women from the population who had had a singleton birth of at least 37 completed weeks gestation. All birth outcomes were included. Unconditional logistic regression was used to assess the association of very preterm birth with type and number of prior abortions, prior preterm births and sociodemographic factors. Using the complex combinations of prior pregnancy experiences of women (including nulligravidity), we showed that a history of prior childbirth (at term) with no preterm births gave the lowest risk of very preterm birth. With this group as the reference category, odds ratios of more than two were associated with all other prior reproductive histories. There was no evidence of difference in risk between types of abortion (i.e. spontaneous or induced) although the risk increased if a prior preterm birth had also occurred. There was an increasing risk of very preterm birth associated with increasing numbers of abortions. This method of data analysis reveals consistent and similar risks for very preterm birth following spontaneous or induced abortions. The findings point to the need to explore commonalities rather than differences in regard to the impact of abortion on subsequent births.

The prevalence and intractability of preterm birth is known as is its association with reproductive history, but the relationship with sequence of pregnancies is not well studied. The data were from a population-based case-control study, conducted in Victoria, Australia. The study recruited women giving birth between April 2002 and April 2004 from 73 maternity hospitals. Detailed reproductive histories were collected by interview a few weeks after the birth. The cases were 603 women having a singleton birth between 20 and32 weeks gestation (very preterm births including terminations of pregnancy). The controls were 796 randomly selected women from the population having a singleton birth of at least 37 completed weeks gestation. Unconditional logistic regression was used to assess the association of very preterm birth with sequence of pregnancies defined by their outcome (prior abortion - spontaneous or induced, and prior preterm or term birth) with adjustment for sociodemographic factors. The outcomes of each prior pregnancy, stratified by pregnancy order, and starting with the pregnancy immediately before the index or control pregnancy, were categorised as one of abortion, preterm birth or term birth. We showed that each of these prior pregnancy events was an independent risk of very preterm birth. This finding does not support the hypothesis of a neutralising effect of a term birth after an abortion on the subsequent risk for very preterm birth and is further evidence for the cumulative or increasing risk associated with increasing numbers of prior abortions or preterm births.

Interpretation of antibody to hepatitis C virus (HCV) in patients with liver disease is difficult due to false-positive reactivity in some conditions. To evaluate the feasibility of HCV in archival material, HCV was sought in formalin-fixed, paraffin-embedded liver biopsy specimens. Nested polymerase chain reaction was used to detect hepatitis C virus in formalin-fixed, paraffin-embedded liver biopsy specimens after total RNA was extracted from tissue by proteinase K digestion and phenol/chloroform purification. The relative efficiency of amplification of HCV RNA from formalin-fixed material was estimated semiquantitatively by serial dilution of cDNA synthesised from RNA extracted from fresh and formalin-fixed sections from the same liver. Although HCV RNA could be detected in formalin-fixed liver tissue by nested PCR in 5/5 cases in which HCV was detected in serum, amplification was ∼5-fold less efficient than when HCV was amplified from fresh tissue. Nevertheless, nested PCR of HCV from formalin-fixed liver tissue represents a useful technique in addressing some important questions related to the pathogenesis of liver disease. © 1992 Wiley-Liss, Inc.

Summary Background Despite limited evidence evaluating early postnatal discharge, length of hospital stay has declined dramatically in Australia since the 1980s. The recent rising birth rate in Victoria, Australia has increased pressure on hospital beds, and many services have responded by discharging women earlier than planned, often with little preparation during pregnancy. We aimed to explore the views of women and their partners regarding a number of theoretical postnatal care ‘packages’ that could provide an alternative approach to early postnatal care. Methods Eight focus groups and four interviews were held in rural and metropolitan Victoria in 2006 with participants who had experienced a mix of public and private maternity care. These included 8 pregnant women, 42 recent mothers and 2 male partners. All were fluent in English. Focus groups explored participants’ experiences and/or expectations of early postnatal care in hospital and at home and their views of alternative packages of postnatal care where location of care shifted from hospital to home and/or hotel. This paper describes the packages and explores and describes what ‘value’ women placed on the various components of care. Findings Overall, women expressed a preference for what they had experienced or expected, which may be explained by the ‘what is must be best’ phenomenon where women place value on the status quo. They generally did not respond favourably towards the alternative postnatal care packages, with concerns about any shorter length of hospital stay, especially for first time mothers. Women were concerned about the safety and wellbeing of their new baby and reported that they lacked confidence in their ability to care for their baby. The physical presence and availability of professional support was seen to alleviate these concerns, especially for first time mothers. Participants did not believe that increased domiciliary visits compensated for forgoing the perceived security and value of staying in hospital. Women generally valued staying in hospital for the length of time they felt they needed above all other factors. Key conclusions and implications for practice Women were concerned about shortened postnatal length of hospital stay and these concerns must be considered when changes are planned in maternity service provision. Any moves towards shorter postnatal length of stay must be comprehensively evaluated with consideration given to exploring consumer views and satisfaction. There is also a need for flexibility in postnatal care that acknowledges women's individual needs.

Many tissues, including hepatobiliary cells, express neutral endopeptidase (CD10), encoded by MME. Serum neutral endopeptidase activity (NEA) has been recommended as a marker of cholestasis in adults but not in children with Alagille syndrome (AGS). We investigated ontogenic and disease-related differences in the expression of CD10. CD10 was found on canalicular surfaces of hepatocytes throughout the lobule in 16 adults and in 31 children agedor =24 months, with and without cholestasis, but not in 39 children aged24 months, with and without cholestasis. Ten AGS children aged 2 months to 6 years lacked any canalicular CD10 expression. Cholangiocyte apices and/or intrasinusoidal granulocytes marked for CD10 in all subjects. Liver membrane fractions from a child with cholestasis aged24 months and from 2 AGS patients aged24 months contained reduced levels of CD10. In contrast, AGS children and all controls expressed CD10 similarly on granulocytes. MME mRNA was found in the liver of children aged24 months and of adults, all with cholestasis, and of AGS patients. Granulocyte MME mRNA levels were similar among all study subjects; however, liver MME mRNA levels were 6- to 140-fold less than in normal adults in all cholestatic subjects, including AGS children. Methylation of the MME promoter was not detected in the liver of AGS children. In conclusion, hepatocytes in early childhood physiologically lack immunohistochemically detectable CD10. Reduced MME mRNA in AGS is not due to MME promoter methylation. Liver CD10 in childhood appears to undergo reduced synthesis or rapid degradation, which persists in AGS. Absence of CD10 expression thus may limit NEA as a marker of cholestasis in young patients and in AGS.

Summary This paper describes an evaluation study that aimed to assess data collection processes in a population-based case–control study of very preterm birth. Semi-structured interviews were conducted with the 10 research interviewers to determine their perceptions of the hypotheses, the differences between interviewing cases and controls and between modes of interview, their reactions to questions which they had to ask in interviews and their training. Time and cost of the collection of data were also considered. None of the research interviewers identified which of the questions in the interview constituted the primary hypothesis. All interviewers interviewed cases and controls (including mothers of twins and singletons), and collected data face-to-face and by telephone. Whilst half of the interviewers had no issue with asking sensitive questions, hearing of intimate partner violence, risk-taking behaviour and inappropriate medical care were confronting for others. Training was judged as adequate, as was the continuing support of the project co-ordinator. On average, interviewing took 40% of research interviewers’ time, and 25 interviews were completed per effective full-time month of interviewer time. Each interview cost approximately $170AU to complete. In relation to this case–control study, interviewer bias may be lessened since research interviewers had been unable to infer the hypothesis of the study. All interviewers had interviewed both cases and controls and any systematic differences can be adjusted for in the analysis.

Aim: To describe the process involved in obtaining ethics approval for a study aiming to recruit women from all maternity hospitals in Victoria, Australia. Design: Observational data of the application process involving 85 hospitals throughout Victoria in 2001. Results: Twenty three of the 85 hospitals had a Human Research Ethics Committee (HREC) constituted in accordance with the National Health and Medical Research Council requirements; 27 agreed to accept decisions from other hospitals having HRECs and 27 relied on ethics advisory committees, hospital managers, clinical staff, quality assurance committees or lawyers for ethics decisions. Four of the latter did not approve the study. Eight hospitals no longer provided maternity services in the recruitment period. The process took 16 months, 26 000 sheets of paper, 258 copies of the application and the cost was about $30 000. Approval was eventually obtained for recruitment at 73 hospitals. Discussion: Difficulties exist in obtaining timely ethics approval for multicentre studies due to a complex uncoordinated system. All hospitals should have explicit protocols for dealing with research ethics applications so that they can be processed in a straightforward and timely manner. To facilitate this, those without properly constituted HRECs should be affiliated with one hospital that has an HREC. (author abstract)

Objectives to present issues associated with recruitment of women in maternity hospitals to a population-based case-control study of very preterm birth. Design a descriptive study of the recruitment process. Setting all maternity hospitals, including three providing neonatal intensive care services, in Victoria, Australia from April 2002 to April 2004. Participants cases were women who had a singleton birth between 20 and 31+6 weeks of gestation. Controls were a random selection of women having a singleton birth of at least 37 completed weeks of gestation in the same time period as the cases. Measurements and findings ethical approval was obtained from 73 of 77 maternity hospitals. Hospitals considered that privacy laws required that women should be approached initially by hospital staff for recruitment into the research study. Extensive effort was put into liaising with hospital personnel, determining hospital-specific protocols for approaching women and developing relationships with doctors, midwives and ward clerks. Recurrent reminders were provided to all hospitals. Of the 2785 women (cases and controls) ascertained as eligible, 13% of cases with surviving babies, 11% of controls and 74% of cases whose babies did not survive were not approached to participate in the study. Within these groups, there was variation by gestation and hospital. Once women were approached, 72% were interviewed. The interview response proportion was 50%. Key conclusions recruitment to studies in the maternity setting in the postpartum period is a challenge. Barriers to recruitment that may have introduced selection bias in this study include: recruitment at many hospitals; short postnatal hospital stay; reliance on hospital staff to make the first approach to women; and low response from women whose babies did not survive. A dialogue between researchers and clinical midwives is proposed to explore ways of increasing researchers' understanding of the complex and demanding hospital environment, and to improve research awareness among clinical midwives.

Objective to describe how women's maternal health, particularly at a psychosocial level, is assessed and promoted during the postnatal hospital stay. Design postal survey of public hospitals providing postnatal care and interviews with care providers. Setting all publicly funded maternity units and selected health professionals in Victoria, Australia. Participants hospital postal survey: sixty six hospital respondents; interviews: 38 maternity unit managers, clinical midwives and medical practitioners. Findings there was little consistency across the State in relation to routine observations of the mother. Physical checks were much more common than enquiring about how women felt physically. Practice in psychosocial assessment was also diverse, with care plans/maps (clinical pathways) being the main tool to guide assessment. Most participants reported that psychosocial assessment was undertaken during pregnancy. Follow-up after birth also varied. Hospital respondents reported that emotional well-being is assessed postnatally by observation and conversation with women. Participants who were interviewed reported that midwives had mixed skills in assessing and dealing with complex psychosocial issues. Three hospitals administer the Edinburgh Postnatal Depression Scale to women in the days after birth, and three hospitals provide routine sessions of structured debriefing. Survey participants reported that the busy and, at times, chaotic nature of postnatal wards affected the provision of care and the level of psychosocial support offered to women. Key conclusions although one of the stated aims of early postnatal care is the promotion of maternal well-being, the diversity of practices and the routine nature of many of these practices suggest that care is often not individualised or woman-centred. The reliance of detecting and managing women with particular psychosocial issues during pregnancy results in this aspect of care being given less priority postnatally than may be ideal. Implications for practice strategies are required to provide health professionals with guidelines and skills to enhance the detection of women who have, or have the potential to develop, health problems after birth. This requires a reorganisation of the way early postnatal care is provided in relation to the use of routine practices; the ability of caregivers to spend time with women in an environment that offers privacy and confidentiality; the structuring of care around individual needs; and opportunities for women to be cared for by caregiver/s with whom they have met before.

Objective Public health research is an endeavour that often involves multiple relationships, far-reaching collaborations, divergent expectations and various outcomes. Using the Tall Girls Study as a case study, this paper will present and discuss a number of methodological, ethical and legal challenges that have implications for other public health research. Approach The Tall Girls Study was the first study to examine the long-term health and psychosocial effects of oestrogen treatment for tall stature. Results In undertaking this study the research team overcame many hurdles: in maintaining collaboration with treating clinicians and with the women they had treated as girls - groups with opposing points of view and different expectations; using private practice medical records to trace women who had been patients up to forty years earlier; and exploring potential legal issues arising from the collection of data related to treatment. Conclusion While faced with complex challenges, the Tall Girls Study demonstrated that forward planning, ongoing dialogue between all stakeholders, transparency of processes, and the strict adherence to group-developed protocols were keys to maintaining rigour while undertaking pragmatic research. Implications Public health research often occurs within political and social contexts that need to be considered in the planning and conduct of studies. The quality and acceptability of research findings is enhanced when stakeholders are engaged in all aspects of the research process.

Background & Aims: Patients with severe bile salt export pump (BSEP) deficiency present as infants with progressive cholestatic liver disease. We characterized mutations of ABCB11 (encoding BSEP) in such patients and correlated genotypes with residual protein detection and risk of malignancy. Methods: Patients with intrahepatic cholestasis suggestive of BSEP deficiency were investigated by single-strand conformation polymorphism analysis and sequencing of ABCB11. Genotypes sorted by likely phenotypic severity were correlated with data on BSEP immunohistochemistry and clinical outcome. Results: Eighty-two different mutations (52 novel) were identified in 109 families (9 nonsense mutations, 10 small insertions and deletions, 15 splice-site changes, 3 whole-gene deletions, 45 missense changes). In 7 families only a single heterozygous mutation was identified despite complete sequence analysis. Thirty-two percent of mutations occurred in > 1 family, with E297G and/or D482G present in 58% of European families (52/89). On immunohistochemical. analysis (88 patients), 93% had abnormal or absent BSEP staining. Expression varied most for E297G and D482G, with some BSEP detected in 45% of patients (19/42) with these mutations. Hepatocellular carcinoma or cholangiocarcinoma developed in 15% of patients (19/128). Two protein-truncating mutations conferred particular risk; 38% (8/21) of such patients developed malignancy versus 10% (11/107) with potentially less severe genotypes (relative risk, 3.7 [confidence limits, 1.7-8.1; P = .003]). Conclusions: With this study, > 100 ABCB11 mutations are now identified. Immunohistochemically detectable BSEP is typically absent, or much reduced, in severe disease. BSEP deficiency confers risk of hepatobiliary malignancy. Close surveillance of BSEP-deficient patients retaining their native liver, particularly those carrying 2 null mutations, is essential.