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Background The naturally occurring male-to-female (M/F) ratio at birth is 1.05. Higher ratios found primarily in countries across Asia have been attributed to prenatal sex selection due to son preference. There is growing evidence that sex-selective practices continue following migration; however, little is known about these practices following migration to Australia. Methods In this population-based study we assessed M/F ratios at birth per mother’s country of birth for all registered births 1999–2015 in Victoria, Australia (n = 1 191 250). We also compared the M/F ratio among births to mothers born elsewhere to that of mothers born in Australia, stratified by time period and parity. Results Compared with the naturally occurring M/F ratio as well as to the M/F ratio among births to mothers born in Australia, there was an increased ratio of male births to mothers born in India, China and South-East Asia, particularly at higher parities and in more recent time periods (elevated M/F ratios ranged from 1·079 to 1·248, relative risks of male birth ranged from 1·012 to 1·084 with confidence intervals between 1·001 and 1·160 and P-values between 0·005 and 0·039). The most male-biased sex ratios were found among multiple births to Indian-born mothers, and parity of two or more births to Indian and Chinese-born mothers in 2011–15. Conclusions The male-biased sex ratios observed in this study indicate that prenatal sex selection may be continuing following migration to Australia from countries where these practices have been documented. The excess of males among multiple births raises the question as to what role assisted reproduction plays. Findings also suggest that systematic discrimination against females starts in the womb.

Background Sub-Saharan African women are often treated as a single group in epidemiological studies of immigrant birth outcomes, potentially masking variations across countries. Methods Cross-sectional population-based study of 432,567 singleton births in Victoria, Australia comparing mothers born in one of four East African countries (453 Eritreans, 1094 Ethiopians, 1,861 Somali and 1,404 Sudanese) relative to 427,755 Australian-born women was conducted using the Victorian Perinatal Data Collection. Pearson’s chi-square test and logistic regression analyses were performed to investigate disparities and estimate risks of perinatal mortality and other adverse perinatal outcomes after adjustment for confounders selected a priori. Results Compared with mothers born in Australia, East African immigrants as a group had elevated odds of perinatal mortality (ORadj1.83, 95 % CI 1.47, 2.28), small for gestational age births (SGA) (ORadj1.59 95 % CI 1.46, 1.74), very low birthweight (ORadj1.33, 95 % CI 1.11, 1.58) and very preterm birth (ORadj1.55, 95 % CI 1.27, 1.90). However, they had lower odds of preterm birth (ORadj0.86 95 % CI 0.76, 0.98) and macrosomia (ORadj0.65 95 % CI 0.51, 0.83). Individual country of birth analyses indicated significant variations, with Eritrean women having higher odds of very low birthweight (ORadj1.80, 95 % CI 1.09, 2.98), very preterm birth (ORadj 1.96, 95 % CI 1.08, 3.58), small for gestational age births (ORadj 1.52, 95 % CI 1.14, 2.03) and perinatal mortality (ORadj 2.69, 95 % CI 1.47, 4.91). Sudanese women had higher odds of low birthweight (ORadj 1.36, 95 % CI 1.10, 1.68), very low birthweight (ORadj 1.53, 95 % CI 1.13, 2.07), very preterm birth (ORadj 1.78, 95 % CI 1.26, 2.53), small for gestational age births (ORadj 2.13, 95 % CI 1.84, 2.47) and perinatal mortality (ORadj 2.10, 95 % CI 1.44, 3.07)]. Ethiopian women differed from Australian-born women only in relation to higher odds of very preterm birth, (ORadj1.70 95 % CI 1.16, 2.50), and only Somali-women had significantly lower odds of preterm birth (ORadj0.70 95 % CI 0.56, 0.88). Conclusions Overall, East African countries of birth were associated with increased perinatal death and some adverse perinatal outcomes; suggesting the need for strategies to enhance surveillance and health care delivery for these women. Analysis by individual country of birth groups has shown women from Eritrea and Sudan are particularly at increased risk of adverse outcomes, demonstrating the importance of antenatal identification of maternal country of birth. Electronic supplementary material The online version of this article (doi:10.1186/s12884-016-0886-z) contains supplementary material, which is available to authorized users.

Objective:To compare the effect of comorbidities on the phenotype and outcomes of preeclampsia.Methods: A matched retrospective cohort study of women delivering at a tertiary maternity center following a diagnosis of preeclampsia. We collected data on signs and symptoms, biochemical markers, and maternal and perinatal outcomes.Results:We studied 474 women; 158 women with and 316 without comorbidities. Compared to women without comorbidities, women with comorbidities delivered earlier. They suffered fewer maternal but more neonatal complications.Conclusion: Women with comorbidities receive earlier intervention than women without comorbidities, which may lead to fewer maternal complications but worse neonatal outcomes.

Timely delivery of infants suspected of having fetal growth restriction (FGR) is a balance between preventing stillbirth and minimizing prematurity, particularly because many infants with suspected FGR have normal growth.To explore the association between iatrogenic delivery for suspected FGR and childhood school outcomes.A retrospective whole-population cohort study linking perinatal data from births 32 weeks' or more gestation between January 1, 2003, to December 31, 2013, to developmental and educational test scores at preparatory school, and at school grades 3, 5, and 7 in Victoria, Australia. Follow-up was concluded in 2019.Suspicion or nonsuspicion of FGR, presence or absence of iatrogenic delivery (defined as early induction of labor or cesarean delivery prior to labor) for suspected FGR, and presence or absence of small for gestational age (SGA).The coprimary outcomes were being in the bottom 10th percentile on 2 or more of 5 developmental domains at school entry and being below the national minimum standard on 2 or more of 5 educational domains in grades 3, 5, or 7.In the birth population of 705 937 infants, the mean gestation at birth was 39.1 (SD, 1.5) weeks and the mean birth weight was 3426 (SD, 517) grams. The birth population linked to 181 902 children with developmental results and 425 717 children with educational results. Compared with infants with severe SGA (birth weight3rd percentile) not suspected of having FGR, infants with severe SGA delivered for suspected FGR were born earlier (mean gestation, 37.9 weeks vs 39.4 weeks). They also had a significantly increased risk of poor developmental outcome at school entry (16.2% vs 12.7%; absolute difference, 3.5% [95% CI, 0.5%-6.5%]); adjusted odds ratio [aOR], 1.36 [95% CI, 1.07-1.74]) and poor educational outcomes in grades 3, 5, and 7 (for example, in grade 7: 13.4% vs 10.5%; absolute difference, 2.9% [95% CI, 0.4%-5.5%]); aOR, 1.33 [95% CI, 1.04-1.70]). There was no significant difference between infants with normal growth (birth weight ≥10th percentile) delivered for suspected FGR and those not suspected of having FGR in developmental outcome (8.6% vs 8.1%; absolute difference, 0.5% [95% CI, -1.1% to 2.0%]); aOR, 1.17 [95% CI, 0.95-1.45]) or educational outcome in grade 3, 5 or 7, despite being born earlier (mean gestation, 38.0 weeks vs 39.1 weeks).In this exploratory study conducted in Victoria, Australia, iatrogenic delivery of infants with severe SGA due to suspected FGR was associated with poorer school outcomes compared with infants with severe SGA not suspected of having FGR. Iatrogenic delivery of infants with normal growth due to suspected FGR was not associated with poorer school outcomes compared with infants with normal growth not suspected of having FGR.

Introduction Preterm birth is a major cause of perinatal morbidity and mortality worldwide. In many countries preterm birth rates are increasing, largely as a result of increases in iatrogenic preterm birth, whereas in other countries rates are stable or even declining. The objective of the study is to describe trends in singleton preterm births in Victoria from 2007 to 2017 in relation to trends in perinatal mortality to identify opportunities for improvements in clinical care. Material and methods We conducted a consecutive cross‐sectional study in all women with a singleton pregnancy giving birth at ≥20 weeks of pregnancy in Victoria, Australia, between 2007 and 2017, inclusive. Rates of preterm birth and perinatal mortality were calculated and trends were analyzed in all pregnancies, in pregnancies complicated by fetal growth problems, hypertension, (pre)eclampsia or prelabor rupture of membranes (PROM), and in (low‐risk) pregnancies not complicated by any of these conditions. Results There were 811 534 singleton births between 2007 and 2017. Preterm birth increased from 5.9% (4074 births) to 6.4% (4893 births; P

AIM: Timely delivery of fetal growth restriction (FGR) is a balance between avoiding stillbirth and minimising prematurity. We sought to assess the neonatal outcomes for babies suspected of FGR, both true and false positives. METHODS: This population cohort study examined all singleton births in Victoria, Australia from 2000 to 2017 (n = 1 231 415). Neonatal morbidities associated with neonatal intensive care unit (NICU) admission were assessed for babies born ≥32 weeks' with severe FGR (

Objective An estimated two billion people worldwide live with hepatitis B virus (HBV) infection. Many of these are women of reproductive age. Studies that have examined pregnancy outcomes in women living with HBV have reported conflicting results in relation to the incidence of gestational diabetes (GDM). The aim of this study is to examine if gestational diabetes is more common in women with chronic HBV residing in a non-Asian country. Design Cross-sectional study. Setting Victoria, Australia. Population All singleton births between 2009 and 2017. Methods Poisson regression was performed to determine whether gestational diabetes is more common in women with HBV than in women without HBV taking into account other risk factors such as maternal age, body mass index (BMI), parity and country of birth. Main outcome measure Gestational diabetes diagnosis in women with chronic HBV infection. Results For women with HBV, the unadjusted incidence risk ratio for GDM was 1.75 (95% CI 1.6-1.9). After adjusting for region of birth, BMI, parity, age and smoking, the adjusted incidence risk ratio was 1.2 (95% CI 1.1-1.3). The highest incidence (37.1%) of GDM was in women with HBV and a BMI of >40. Conclusions The findings from this study confirm an association between HBV and GDM. Tweetable abstract HBV is associated with GDM with an incidence risk ratio for GDM of 1.75 (95% CI 1.6-1.9).

OBJECTIVE To assess the impact of increasing obstetric intervention on birthweight centiles. DESIGN Retrospective cohort study of births in five 2-year epochs: 1983-84, 1993-94, 2003-2004, 2013-2014 and 2016-2017. POPULATION 665 205 singleton births at ≥32 weeks' gestation. SETTING All maternity services in Victoria, Australia. METHODS For each epoch, we calculated the birthweight cutoffs defining each birthweight centile at 34, 37 and 40 weeks' gestation. We calculated rates of iatrogenic delivery over time. We then calculated the number of babies whose birthweight would have classified them as ≥3rd centile based on 1983-84 centile definitions but as

Stillbirth and preterm birth (PTB) remain two of the most important, unresolved challenges in modern pregnancy care. Approximately 10% of all births are preterm with nearly one million children dying each year due to PTB. It remains the most common cause of death among children under five years of age. The numbers for stillbirth are no less shocking with 2.6 million babies stillborn each year. With minimal impact on the rate of these adverse birth outcomes over the past decade there is an urgent need to identify more effective interventions to tackle these problems. In this retrospective cohort study, we used whole-of-population data, to determine if maternal immunization during pregnancy against influenza and/or pertussis, is associated with a lower risk of PTB, delivering a small-for-gestational age (SGA) infant, developing preeclampsia or stillbirth. Women with a singleton pregnancy at 28 or more weeks’ gestation delivering in Victoria, Australia from July 2015 to December 2018 were included in the analysis. Log-binomial regression was used to measure the relationship between vaccination during pregnancy against influenza and against pertussis, with preterm birth, SGA, preeclampsia and stillbirth. Variables included in the adjusted model were maternal age, body mass index, first or subsequent birth, maternal Indigenous status, socio-economic quintile, smoking, public or private maternity care and metropolitan or rural location of the hospital. Women who received influenza vaccine were 75% less likely to have a stillbirth (aRR 025; 95% CI 0.20, 0.31), and 31% less likely to birth

OBJECTIVE To assess the impact of publicly reporting a statewide fetal growth restriction (FGR) performance indicator. DESIGN Retrospective cohort study from 2000 to 2017. SETTING All maternity services in Victoria, Australia. POPULATION A total of 1 231 415 singleton births at ≥32 weeks of gestation. METHODS We performed an interrupted time-series analysis to assess the impact of publicly reporting an FGR performance indicator on the rate of detection for severe cases of small for gestational age (SGA). Rates of perinatal mortality and morbidity and obstetric intervention were assessed for severe SGA pregnancies and pregnancies delivered for suspected SGA. MAIN OUTCOME MEASURES Gestation at delivery, obstetric management and perinatal outcome. RESULTS The public reporting of a statewide FGR performance indicator was associated with a steeper reduction per quarter in the percentage of severe SGA undelivered by 40 weeks of gestation, from 0.13 to 0.51% (P = 0.001), and a decrease in the stillbirth rate by 3.3 per 1000 births among those babies (P = 0.01). Of babies delivered for suspected SGA, the percentage with birthweights ≥ 10th centile increased from 41.4% (n = 307) in 2000 to 53.3% (n = 1597) in 2017 (P

BACKGROUND: Severe postpartum haemorrhage (PPH) is a serious clinical problem that is increasing in incidence. AIM: To identify risk factors for severe PPH. MATERIALS AND METHODS: Population-based retrospective cohort study of all women who gave birth in Victoria in 2009-2013 using the validated Victorian Perinatal Data Collection. Three multivariable logistic regression models estimated the adjusted risk of severe PPH. Adjusted odds ratios (aOR) and their 95% confidence intervals are reported. The primary outcome was severe PPH (estimated blood loss of ≥1500 mL). RESULTS: Severe PPH occurred in 1.4% of all births (n = 5122). Maternal characteristics significantly associated with severe PPH included: multiple pregnancy; older maternal age; overweight/obesity; first births. Other risk factors included placental complications, macrosomia, instrumental vaginal birth, third and fourth degree perineal lacerations, in-labour caesarean section, birth at a gestation other than 37-41 weeks, duration of labour 12 to

International audience; Background and aims: Smoking in pregnancy causes substantial avoidable harm to mothers and offspring; nicotine replacement therapy (NRT) may prevent this, and is used to help women to quit. A recently updated Cochrane Review of randomized controlled trials (RCTs) investigating impacts of NRT in pregnancy focuses primarily on efficacy data, but also reports adverse impacts from NRT. Here we identify and summarize NRT impacts on adverse pregnancy outcomes reported in non-randomized controlled trials (non-RCTs).Methods: Systematic reviews and meta-analyses of RCTs and non-RCT studies of NRT in pregnancy, with design-specific risk of bias assessment and grading of recommendations, assessment, development and evaluations (GRADE) criteria applied to selected outcomes.Findings: Relevant Cochrane Review findings are reported alongside those from this new review. Seven RCTs were included; n = 2340. Nine meta-analyses were performed; non-statistically significant estimates indicated potentially reduced risk from NRT compared with smoking for mean birth weight, low birth weight, preterm birth, intensive care admissions, neonatal death, congenital anomalies and caesarean section and potentially increased risks for miscarriage and stillbirth. GRADE assessment for mean birth weight and miscarriage outcomes indicated 'low' confidence in findings. Twenty-three non-RCTs were included; n = 931 163. Eleven large studies from five routine health-care cohorts reported clinical outcomes; 12 small studies investigated mainly physiological outcomes within in-patient women given NRT. Findings from meta-analyses for congenital anomalies, stillbirth and preterm birth were underpowered and not in a consistent direction; GRADE assessment of confidence in findings was 'very low'. Routine health-care studies were of higher quality, but implications of reported findings were unclear as there was inadequate measurement and reporting of women's smoking.Conclusions: Available evidence from randomized controlled trials and non-randomized comparative studies does not currently provide clear evidence as to whether maternal use of nicotine replacement therapy during pregnancy is harmful to the fetus.

Background Preterm birth is a major cause of perinatal morbidity and mortality worldwide. In many countries, the preterm birth rate in women with a multiple pregnancy is increasing, mostly due to an increase in iatrogenic preterm birth. Aims To investigate trends in preterm birth in twin pregnancies in Victoria, Australia, in relation to maternal and perinatal complications. Materials and methods We conducted a retrospective population-based cohort study in all women with a twin pregnancy who delivered at or after 20 weeks of gestation in the state of Victoria, Australia between 2007 and 2017. Annual spontaneous and iatrogenic preterm birth rates were calculated and trends analysed. Incidence of adverse pregnancy outcomes, maternal complications and risk factors for preterm birth were analysed. Results We studied 12 757 women with a twin pregnancy. Between 2007 and 2017 the preterm birth rate increased from 641/1231 (52%) to 803/1158 (69%), mainly due to an increase in iatrogenic preterm birth from 342/1231 (28%) to 567/1158 (49%). This was irrespective of the presence of pregnancy complications. Our study showed neither a decrease in perinatal mortality from 28 weeks of gestation nor in preterm average weekly prospective stillbirth risk. Conclusion Preterm birth rates in twins in Victoria are increasing, mainly driven by an increase in iatrogenic preterm birth. This occurred both in complicated and non-complicated twin pregnancies, and has not been accompanied by reduction in perinatal mortality from 28 weeks.

BACKGROUND: Tobacco smoking in pregnancy causes serious health problems for the developing fetus and mother. When used by non‐pregnant smokers, pharmacotherapies (nicotine replacement therapy (NRT), bupropion, and varenicline) are effective for increasing smoking cessation, however their efficacy and safety in pregnancy remains unknown. Electronic cigarettes (ECs) are becoming widely used, but their efficacy and safety when used for smoking cessation in pregnancy are also unknown. OBJECTIVES: To determine the efficacy and safety of smoking cessation pharmacotherapies and ECs used during pregnancy for smoking cessation in later pregnancy and after childbirth, and to determine adherence to smoking cessation pharmacotherapies and ECs for smoking cessation during pregnancy. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 May 2019), trial registers, and grey literature, and checked references of retrieved studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) conducted in pregnant women, comparing smoking cessation pharmacotherapy or EC use with either placebo or no pharmacotherapy/EC control. We excluded quasi‐randomised, cross‐over, and within‐participant designs, and RCTs with additional intervention components not matched between trial arms. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane methods. The primary efficacy outcome was smoking cessation in later pregnancy; safety was assessed by 11 outcomes (principally birth outcomes) that indicated neonatal and infant well‐being. We also collated data on adherence to trial treatments. We calculated the risk ratio (RR) or mean difference (MD) and the 95% confidence intervals (CI) for each outcome for each study, where possible. We grouped eligible studies according to the type of comparison. We carried out meta‐analyses where appropriate. MAIN RESULTS: We included 11 trials that enrolled a total of 2412 pregnant women who smoked at enrolment, nine trials of NRT and two trials of bupropion as adjuncts to behavioural support, with comparable behavioural support provided in the control arms. No trials investigated varenicline or ECs. We assessed four trials as at low risk of bias overall. The overall certainty of the evidence was low across outcomes and comparisons as assessed using GRADE, with reductions in confidence due to risk of bias, imprecision, and inconsistency. Compared to placebo and non‐placebo (behavioural support only) controls, there was low‐certainty evidence that NRT increased the likelihood of smoking abstinence in later pregnancy (RR 1.37, 95% CI 1.08 to 1.74; I² = 34%, 9 studies, 2336 women). However, in subgroup analysis by comparator type, there was a subgroup difference between placebo‐controlled and non‐placebo controlled RCTs (test for subgroup differences P = 0.008). There was unclear evidence of an effect in placebo‐controlled RCTs (RR 1.21, 95% CI 0.95 to 1.55; I² = 0%, 6 studies, 2063 women), whereas non‐placebo‐controlled trials showed clearer evidence of a benefit (RR 8.55, 95% CI 2.05 to 35.71; I² = 0%, 3 studies, 273 women). An additional subgroup analysis in which studies were grouped by the type of NRT used found no difference in the effectiveness of NRT in those using patches or fast‐acting NRT (test for subgroup differences P = 0.08). There was no evidence of a difference between NRT and control groups in rates of miscarriage, stillbirth, premature birth, birthweight, low birthweight, admissions to neonatal intensive care, caesarean section, congenital abnormalities, or neonatal death. In one study infants born to women who had been randomised to NRT had higher rates of 'survival without developmental impairment' at two years of age compared to the placebo group. Non‐serious adverse effects observed with NRT included headache, nausea, and local reactions (e.g. skin irritation from patches or foul taste from gum), but data could not be pooled. Adherence to NRT treatment regimens was generally low. We identified low‐certainty evidence that there was no difference in smoking abstinence rates observed in later pregnancy in women using bupropion when compared to placebo control (RR 0.74, 95% CI 0.21 to 2.64; I² = 0%, 2 studies, 76 women). Evidence investigating the safety outcomes of bupropion use was sparse, but the existing evidence showed no difference between the bupropion and control group. AUTHORS' CONCLUSIONS: NRT used for smoking cessation in pregnancy may increase smoking cessation rates in late pregnancy. However, this evidence is of low certainty, as the effect was not evident when potentially biased, non‐placebo‐controlled RCTs were excluded from the analysis. Future studies may therefore change this conclusion. We found no evidence that NRT has either positive or negative impacts on birth outcomes; however, the evidence for some of these outcomes was also judged to be of low certainty due to imprecision and inconsistency. We found no evidence that bupropion may be an effective aid for smoking cessation during pregnancy, and there was little evidence evaluating its safety in this population. Further research evidence on the efficacy and safety of pharmacotherapy and EC use for smoking cessation in pregnancy is needed, ideally from placebo‐controlled RCTs that achieve higher adherence rates and that monitor infants' outcomes into childhood. Future RCTs of NRT should investigate higher doses than those tested in the studies included in this review.

Background Understanding the prevalence of, and factors associated with, caesarean birth among immigrant populations is essential for appropriate antenatal and postnatal resource allocation. Aims To compare rates of caesarean birth between one of the largest immigrant populations of women giving birth in Australia (Vietnamese-born women) with those of Australian-born women and investigate the odds of unplanned caesarean in these women, controlling for maternal characteristics, pregnancy complications and labour management factors. Methods Cross-sectional analysis of data on singleton births in Victoria, Australia; using data from the routinely collected Victorian Perinatal Data Collection. Descriptive analyses comparing maternal and obstetric factors for Vietnamese-born women with Australian-born women were undertaken. Using the more recent nine years of routinely collected data, multivariable logistic regression explored the association between unplanned caesarean birth and maternal country of birth, adjusted for maternal and obstetric factors, admission status and time (n = 468,131). This association was also explored for ‘standard primiparae’ (n = 69,039). Findings Planned and unplanned caesarean births increased dramatically in both Australian-born and Vietnamese-born women between 1984 and 2007. After adjustment for obstetric and maternal factors, Vietnamese-born women were at greater odds of an unplanned caesarean birth compared to Australian-born women (adjusted odds ratio = 1.32, 95% confidence interval = 1.25–1.40). These greater odds were also found among the ‘standard primiparae’ (adjusted odds ratio = 1.22, 95% confidence interval = 1.07–1.40). Conclusion Factors other than clinical risk appear to predispose Vietnamese-born women to unplanned caesarean birth. These may include intrapartum communication, length of residence and familiarity with care systems, and variations in care practices for Vietnamese women.

Problem The rate and severity of postpartum haemorrhage (PPH) are increasing, according to research reports and clinical anecdote, causing a significant health burden for Australian women giving birth. However, reporting a national Australian rate is not possible due to inconsistent reporting of PPH. Background Clinician concerns about the incidence and severity of PPH are growing. Midwives contribute perinatal data on every birth, yet published population-based data on PPH seems to be limited. What PPH information is contributed? What data are publicly available? Do published data reflect the PPH concerns of clinicians? Aim To examine routine public reporting on PPH across Australia. Methods We systematically analysed routine, publicly reported data on PPH published in the most recent perinatal data for each state, territory and national report (up to and including October 2016). We extracted PPH data on definitions, type and method of data recorded, markers of severity, whether any analyses were done and whether any trends or concerns were noted. Findings PPH data are collected by all Australian states and territories however, definitions, identification method and documentation of data items vary. Not all states and territories published PPH rates; those that did ranged from 3.3% to 26.5% and were accompanied by minimal reporting of severity and possible risk factors. Whilst there are plans to include PPH as a mandatory reporting item, the timeline is uncertain. Conclusions Routinely published PPH data lack nationally consistent definitions and detail. All states and territories are urged to prioritise the adoption of nationally recommended PPH items.

Maternal immunisation is an important strategy to reduce neonatal mortality and morbidity. New maternal vaccines such as Respiratory Syncytial Virus (RSV) and Group B streptococcus (GBS) are in development and/or clinical trials. However, little is known about pregnant women's knowledge about these diseases.Women attending antenatal clinics in Melbourne, Australia were invited to complete a questionnaire collecting demographic information, past vaccination history, understanding of risk of GBS and RSV disease in pregnancy and likelihood to accept these theoretical vaccines in the future.495 women (48% born outside of Australia, from 48 different countries) completed the questionnaire. A large number of women had never heard of GBS (63%) or RSV (83%). Women over 35 years, born in Australia and women who had more than one child were more likely to have heard of GBS or RSV (p 0.001). Women who had received influenza or pertussis vaccine in pregnancy were more likely to accept a RSV or GBS vaccine (p 0.001).This study has shown that knowledge of GBS and RSV is poor. However, when provided with information about the two diseases, acceptance of a hypothetical vaccine for both diseases was high. This study highlights the enormous amount of work that needs to be done in educating pregnant women about the seriousness of these two diseases if a future vaccine is ever to be accepted and high coverage achieved among the target population.

Objective To determine the effect of primary midwife-led care (‘caseload midwifery’) on women's experiences of childbirth. Design Randomised controlled trial. Setting Tertiary care women's hospital in Melbourne, Australia. Population A total of 2314 low-risk pregnant women. Methods Women randomised to caseload care received antenatal, intrapartum and postpartum care from a primary midwife, with some care provided by a ‘back-up’ midwife. Women in standard care received midwifery-led care with varying levels of continuity, junior obstetric care or community-based medical care. Main outcome measures The primary outcome of the study was caesarean section. This paper presents a secondary outcome, women's experience of childbirth. Women's views and experiences were sought using seven-point rating scales via postal questionnaires 2 months after the birth. Results A total of 2314 women were randomised between September 2007 and June 2010; 1156 to caseload and 1158 to standard care. Response rates to the follow-up questionnaire were 88 and 74%, respectively. Women in the caseload group were more positive about their overall birth experience than women in the standard care group (adjusted odds ratio 1.50, 95% CI 1.22–1.84). They also felt more in control during labour, were more proud of themselves, less anxious, and more likely to have a positive experience of pain. Conclusions Compared with standard maternity care, caseload midwifery may improve women's experiences of childbirth. Tweetable abstract Primary midwife-led care (‘caseload midwifery’) improves women's experiences of childbirth.

Objective: This paper reports on the logistics of conducting a validation study of a routinely collected dataset against medical records at hospitals to inform planning of similar studies. Method: A stratified random sample of 15 hospitals and two homebirth practitioners was included. Site visits were arranged following consent. In addition to the validation of perinatal data, information was collected regarding logistics. Results: Records at 14 metropolitan and rural hospitals up to 500 km from the research centre, and two homebirth practitioners, were audited. Obtaining consent to participate took between 5 days and 10 months. Auditors visited sites on 101 days, auditing 737 medical record pairs at 16 sites. Median audit time per record was 51.3 minutes; electronic records each took 36 minutes longer than paper. Travel time accounted for nearly one-quarter of audit time. Conclusions: Delays obtaining consents, long travel times and electronic records prolonged audit duration and expense. Employment of experts maximised use of available audit time. Conducting a validation study is a time-consuming and expensive exercise; however, confidence in the accuracy of public health data is vital. Implications: Validation studies are unquestionably important. Three alternative strategies have been proposed to make future studies viable.

IntroductionWomen at high inherited risk of ovarian cancer are advised to undergo risk-reducing bilateral salpingo-oophorectomy (RRBSO) at age 40–45 years or when their families are complete. Most women are premenopausal at this age, so RRBSO will induce surgical menopause. Despite the clear benefits of RRBSO for cancer risk reduction, much less is known about the impact on non-cancer outcomes that contribute to health and well-being and inform surveillance and management strategies.Methods and analysisThis will be a multicentre, prospective cohort study of 105 premenopausal high-risk women undergoing RRBSO and an age-matched comparison group of 105 premenopausal women not planning oophorectomy or pregnancy in the next 2 years. The aim of this study is to measure the impact of RRBSO on sexual function (primary outcome) at 24 months in high-risk premenopausal women compared with the comparison group. Secondary outcomes include menopausal symptoms and menopause-related quality of life, mood, sleep quality, markers of cardiovascular disease and pre-diabetes, bone density and markers of bone turnover, and the impact of hormone replacement therapy use on these outcomes. Data analysis methods will include logistic and linear regression using general estimating equations accounting for the repeated outcome measurements within each participant.Ethics and disseminationThe study has been approved by institutional ethics committees at each participating centre. Findings will be disseminated through peer-reviewed publications and conference presentations, and national and international networks of centres managing high-risk women, and will inform national and international clinical guidelines.Trial registration numberThe pre-results protocol for this trial is registered with the Australian New Zealand Clinical Trials Registry (anzctr.org.au; registration no: ACTRN12615000082505).

Objective: Public health data sets such as the Victorian Perinatal Data Collection (VPDC) provide an important source for health planning, monitoring, policy, research and reporting purposes. Data quality is paramount, requiring periodic assessment of data accuracy. This article describes the conduct and findings of a validation study of data on births in 2011 extracted from the VPDC. Method: Data from a random sample of one percent of births in Victoria in 2011 were extracted from original medical records at the birth hospital and compared with data held in the VPDC. Accuracy was determined for 93 variables. Sensitivity, specificity, positive predictive value and negative predictive value were calculated for dichotomous items. Results: Accuracy of 17 data items was 99% or more, the majority being neonatal and intrapartum items, and 95% or more for 46 items. Episodes of care with the highest proportion of items with accuracy of 95% or more were neonatal and postnatal items at 80 and 64%, respectively. Accuracy was below 80% for nine items introduced in 2009. Agreement between medical records and VPDC data ranged from 48% to 100%, the exception being two highly inaccurate smoking-related items. Reasons for discrepancies between VPDC data and medical records included miscoding, missing and inconsistent information. Conclusion: This study found high levels of accuracy for data reported to the VPDC for births in 2011; however, some data items introduced in 2009 and not previously validated were less accurate. Data may be used with confidence overall and with awareness of limitations for some new items.

A number of diseases over the life course such as cardiovascular disease, diabetes, asthma, cancer, allergies, and neurocognitive impairment occur at differing rates among people of different ethnicities. There is growing evidence to suggest that this is a consequence of fetal programming. Gestational diabetes mellitus (GDM) and hypertensive conditions in pregnancy such as gestational hypertension and preeclampsia both occur at elevated rates in women of certain ethnicities. Women of different ethnicities also experience higher rates of adverse pregnancy outcomes and interventions including preterm birth, low birth weight/small for gestational age, and cesarean birth. All of the outcomes listed above have been linked to fetal programming and may explain the increased rates of chronic diseases among people of different ethnicities. Compounding the issue further are the increasing rates of maternal obesity experienced among women in high-income nations. Emerging evidence has suggested that the associations between obesity, adverse pregnancy outcomes, and life course diseases may also be additive in some ethnicities. Further research is needed to uncover specific mechanisms.

Background There is growing evidence from high-income countries that maternal country of birth is a risk factor for stillbirth. We aimed to examine the association between maternal region of birth and stillbirth between 2000 and 2011 inclusive in Victoria, Australia. Methods Retrospective population based cohort study of all singleton births at 24 or more weeks gestational age from 2000–2011 in Victoria, Australia. Stillbirths due to termination of pregnancy, babies with congenital anomalies and Indigenous mothers were excluded. Main Outcome Measure: Stillbirth. Results Over the 12-year period there were 685,869 singleton births and 2299 stillbirths, giving an overall stillbirth rate of 3·4 per 1000 births. After adjustment for risk factors, compared to women born in Australia/New Zealand, women born in South Asia (aOR 1.27, 95% CI 1.01–1.53, p = 0.01), were more likely to have a stillbirth whereas women born in South East and East Asia were (aOR 0.60, (95% CI 0.49–0.72, p

Objectives Variations in caesarean section (CS) between some immigrant groups and receiving country populations have been widely reported. Often, African immigrant women are at higher risk of CS than the receiving population in developed countries. However, evidence about subsequent mode of birth following CS for African women post-migration is lacking. The objective of this study was to examine differences in attempted and successful vaginal birth after previous caesarean (VBAC) for Eastern African immigrants (Eritrea, Ethiopia, Somalia and Sudan) compared with Australian-born women. Design A population-based observational study was conducted using the Victorian Perinatal Data Collection. Pearson's chi-square test and logistic regression analysis were performed to generate adjusted odds ratios for attempted and successful VBAC. Setting Victoria, Australia. Participants 554 Eastern African immigrants and 24,587 Australian-born eligible women with previous CS having singleton births in public care. Findings 41.5% of Eastern African immigrant women and 26.1% Australian-born women attempted a VBAC with 50.9% of Eastern African immigrants and 60.5% of Australian-born women being successful. After adjusting for maternal demographic characteristics and available clinical confounding factors, Eastern African immigrants were more likely to attempt (OR adj 1.94, 95% CI 1.57–2.47) but less likely to succeed (OR adj 0.54 95% CI 0.41–0.71) in having a VBAC. Conclusion/Implications for practice There are disparities in attempted and successful VBAC between Eastern African origin and Australian-born women. Unsuccessful VBAC attempt is more common among Eastern African immigrants, suggesting the need for improved strategies to select and support potential candidates for vaginal birth among these immigrants to enhance success and reduce potential complications associated with failed VBAC attempt.

Objective To determine whether primary midwife care (caseload midwifery) decreases the caesarean section rate compared with standard maternity care. Design Randomised controlled trial. Setting Tertiary-care women’s hospital in Melbourne, Australia. Population A total of 2314 low-risk pregnant women. Methods Women randomised to caseload received antenatal, intrapartum and postpartum care from a primary midwife with some care by ‘back-up’ midwives. Women randomised to standard care received either midwifery or obstetric-trainee care with varying levels of continuity, or community-based general practitioner care. Main outcome measures Primary outcome: caesarean birth. Secondary outcomes included instrumental vaginal births, analgesia, perineal trauma, induction of labour, infant admission to special/neonatal intensive care, gestational age, Apgar scores and birthweight. Results In total 2314 women were randomised–1156 to caseload and 1158 to standard care. Women allocated to caseload were less likely to have a caesarean section (19.4% versus 24.9%; risk ratio [RR] 0.78; 95% CI 0.67–0.91; P = 0.001); more likely to have a spontaneous vaginal birth (63.0% versus 55.7%; RR 1.13; 95% CI 1.06–1.21; P < 0.001); less likely to have epidural analgesia (30.5% versus 34.6%; RR 0.88; 95% CI 0.79–0.996; P = 0.04) and less likely to have an episiotomy (23.1% versus 29.4%; RR 0.79; 95% CI 0.67–0.92; P = 0.003). Infants of women allocated to caseload were less likely to be admitted to special or neonatal intensive care (4.0% versus 6.4%; RR 0.63; 95% CI 0.44–0.90; P = 0.01). No infant outcomes favoured standard care.

Background As the proportions of older women giving birth increase, there is a growing body of evidence on the increased risks of poorer maternal and perinatal outcomes for this group. However, the associations are not completely understood. This study aimed to establish the prevalence of selected maternal morbidities and examine whether advanced maternal age is associated with a higher risk of morbidity for women giving birth in Victoria. Method Data on all births over 20 weeks‧ gestation for 2005 and 2006 were obtained from the Victorian Perinatal Data Collection. Unadjusted and adjusted analyses were undertaken using logistic regression to examine and quantify the association between advanced maternal age (35 years and older) and selected obstetric morbidities and complications. Results There was evidence of an association between older maternal age and selected morbidities and complications. Older nulliparous women were at highest odds of gestational diabetes (AdjOR, 1.83; 95% CI, 1.67–2.02), placenta praevia (AdjOR, 2.02; 95% CI, 1.68–2.44), multiple birth (AdjOR, 1.80; 95% CI, 1.58–2.06) and caesarean delivery (AdjOR, 1.93; 95% CI, 1.84–2.02). Older multiparous women were at highest odds of gestational diabetes (AdjOR, 2.01; 95% CI, 1.88–2.15) and placenta praevia (AdjOR, 2.11; 95% CI, 1.83–2.44). Conclusions Older women giving birth in Victoria are at an increased risk of a range of obstetric morbidities. Delayed childbearing for an increasing number of women has societal and public health ramifications and will potentially place greater demand on healthcare services.

Background: Women from South Asia have a high incidence of gestational diabetes mellitus (GDM) placing them at risk of adverse pregnancy outcomes. Despite the higher rates of GDM in this group, there are no studies of their experiences of living with GDM in Australia or elsewhere. Aims: We aimed to explore the experiences and understandings of South Asian women in Melbourne, Australia, after diagnosis with GDM. Methods: A qualitative approach was used. Face-to-face in-depth interviews were conducted with 17 immigrant women from South Asia recently diagnosed with GDM. They were interviewed in the language of their choice at two time points: in pregnancy after GDM diagnosis and at six weeks postpartum. Thematic analysis was conducted to identify common patterns and salient themes within and across narratives, also taking into account any divergent experiences. Results: Before the diagnosis of GDM, women’s knowledge and awareness of any diabetes were low. Women and their partners were upset by the diagnosis. Dietary advice received was seen to be challenging in the context of culturally different food habits and consequently managing diet after diagnosis proved difficult. Different attitudes to exercise in pregnancy also raised issues for women. Women said they would try their best to maintain lifestyle modifications postnatally, but were uncertain about sustaining these in the long term. Conclusion: South Asian women require culturally appropriate advice regarding strategies to reduce their risk of GDM as early as possible in pregnancy, ideally at the time pregnancy is confirmed.

Background The rate of caesarean sections around the world is rising each year, reaching epidemic proportions. Although many caesarean sections are performed for concerns about fetal welfare on the basis of abnormal cardiotocography, 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. Previously, fetal scalp blood sampling for pH estimation was performed in the context of an abnormal cardiotocograph, to improve the identification of babies in need of expedited delivery. This test has largely been replaced by lactate measurement, although its validity is yet to be established through a randomised controlled trial. This study aims to test the hypothesis that the performance of fetal scalp blood lactate measurement for women in labour with an abnormal cardiotocograph will reduce the rate of birth by caesarean section from 38 % to 25 % (a 35 % relative reduction). Methods/Design Prospective unblinded randomised controlled trial conducted at a single tertiary perinatal centre. Women labouring with a singleton fetus in cephalic presentation at 37 or more weeks’ gestation with ruptured membranes and with an abnormal cardiotocograph will be eligible. Participants will be randomised to one of two groups: fetal monitoring by cardiotocography alone, or cardiotocography augmented by fetal scalp blood lactate analysis. Decisions regarding the timing and mode of delivery will be made by the treating team, in accordance with hospital protocols. The primary study endpoint is caesarean section with secondary outcomes collected from maternal, fetal and neonatal clinical course and morbidities. A cost effectiveness analysis will also be performed. A sample size of 600 will provide 90 % power to detect the hypothesised difference in the proportion of women who give birth by caesarean section. Discussion This world-first trial is adequately powered to determine the impact of fetal scalp blood lactate measurement on rates of caesarean section. Preventing unnecessary caesarean sections will reduce the health and financial burdens associated with this operation, both in the index and any future pregnancies. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12611000172909

Background 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. Objectives 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. Search methods 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). Selection criteria 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. Data collection and analysis 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. Main results Extensive searching revealed no trials of the use of risk scoring systems to prevent preterm birth. Authors' conclusions 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.

Objective To assess the opinions of pregnant women regarding their weight gain and to assess the level of satisfaction and anxiety provoked by being weighed in clinic. Design Questionnaires were given to women participating in a randomised controlled trial comparing routine weighing in the antenatal clinic with standard care. Setting A tertiary hospital antenatal clinic in Melbourne, Australia. Population In all, 782 healthy pregnant women participated in the randomised controlled trial and 586 responded to the questionnaire. Methods A questionnaire was offered to all participants at 36 weeks of gestation gauging their satisfaction with their weight gain during pregnancy. The intervention group was asked about their level of satisfaction and anxiety provoked by being weighed in clinic. The control group was asked whether they would have liked to be weighed in clinic. Both groups were questioned about the influences on their weight gain. Results Women in both groups were satisfied with their weight gain during pregnancy. Seventy-three percent of women in the intervention group were very comfortable with being weighed in clinic. Approximately half of those in the control group would have favoured being weighed. Twenty-one percent of women said other people influenced their weight gain; mostly family members and two-thirds of them encouraged weight gain. Less than half of the women in the study used weighing scales at home. Conclusion Women were satisfied with being weighed antenatally and it did not cause anxiety. Pregnant women accepted the re-introduction of weighing in the antenatal clinic. Tweetable abstract Women are satisfied with being weighed antenatally and it does not cause anxiety.

Objective To assess whether routinely weighing women at each antenatal visit leads to a difference in gestational weight gain and weight gain within the Institute of Medicine (IOM) recommendation. Design A randomised controlled trial. Setting Antenatal clinics in a tertiary obstetric hospital in Melbourne, Australia. Population Healthy women were enrolled during their antenatal booking visit if they were between 18 and 45 years of age, were

Summary Objective to investigate the views and experiences of postnatal hospital care of a representative sample of Victorian women who gave birth in Victoria, Australia, in 1999. Design postal survey sent to women 5–6 months after giving birth. Setting Victoria, Australia. Participants 1616 women who gave birth in Victoria in a 2-week period in September 1999. Findings 50.8% of women described their postnatal care in hospital as ‘very good'. After adjusting for parity, method of birth, length of stay, model of care and socio-demographic characteristics, specific aspects of care with the greatest negative impact on the overall rating of postnatal care were as follows: midwives perceived as rushed and too busy (adjusted OR=4.59 [95% CI 3.4–6.1]), doctors and midwives perceived as not ‘always' sensitive and understanding (adjusted OR=3.88 [2.8–5.5]), support and advice about going home not ‘very helpful' (adjusted OR=3.18 [2.3–4.5]), help and advice about baby feeding not ‘extremely helpful' (adjusted OR=3.27 [2.1–5.1]), not being given advice about baby feeding (adjusted OR=2.84 [1.2–6.9]). Staying in hospital only 1–2 days (adjusted OR=2.00 [1.2–3.4]), and not knowing any of the midwives in the postnatal ward (adjusted OR=1.80 [1.3–2.4]) were also associated with less positive ratings of postnatal hospital care. Key conclusions and implications for practice The 2000 Survey shows that women rate early postnatal care in hospital far less favourably than care in pregnancy, labour and birth. The findings indicate that interactions with caregivers are a major influence on women's overall rating of postnatal hospital care. Acting on these findings requires a greater focus on communication and listening skills, attention to staffing levels, and leadership promoting more women-centred care in postnatal wards.

Background: Maternal mortality and morbidity vary substantially worldwide. It is unknown if these geographic differences translate into disparities in severe maternal morbidity among immigrants from various world regions. We assessed disparities in severe maternal morbidity between immigrant women from various world regions giving birth in three high-immigration countries. Methods: We used population-based delivery data from Victoria; Australia and Ontario, Canada and national data from Denmark, in the most recent 10-year period ending in 2010 available to each participating centre. Each centre provided aggregate data according to standardized definitions of the outcome, maternal regions of birth and covariates for pooled analyses. We used random effects and stratified logistic regression to obtain odds ratios (ORs) with 95% confidence intervals (95% CIs), adjusted for maternal age, parity and comparability scores. Results: We retrieved 2,322,907 deliveries in all three receiving countries, of which 479,986 (21%) were to immigrant women. Compared with non-immigrants, only Sub-Saharan African women were consistently at higher risk of severe maternal morbidity in all three receiving countries (pooled adjusted OR: 1.67; 95% CI: 1.43, 1.95). In contrast, both Western and Eastern European immigrants had lower odds (OR: 0.82; 95% CI: 0.70, 0.96 and OR: 0.64; 95% CI: 0.49, 0.83, respectively). The most common diagnosis was severe pre-eclampsia followed by uterine rupture, which was more common among Sub-Saharan Africans in all three settings. Conclusions: Immigrant women from Sub-Saharan Africa have higher rates of severe maternal morbidity. Other immigrant groups had similar or lower rates than the majority locally born populations.

Aims Several socio-cultural and biomedical risk factors for gestational diabetes mellitus (GDM) are modifiable. However, few studies globally have examined socio-cultural associations. To eliminate confounding of increased risk of diabetes in subsequent pregnancies, elucidating socio-cultural associations requires examination only of first pregnancies. Methods Data for all women who delivered their first child in Victoria, Australia between 1999 and 2008 were extracted from the Victorian Perinatal Data Collection. Crude and adjusted GDM rates were calculated. Multivariate logistic regression was used to examine odds of GDM within and between socio-cultural groups. Results From 1999 to 2008, 269,682 women delivered their first child in Victoria. GDM complicated 11,763 (4.4%) pregnancies and burden increased with maternal age, from 2.1% among women aged below 25 years at delivery to 7.0% among those aged 35 years or more. Among younger women, GDM rates were relatively stable across socioeconomic levels. Amongst older women GDM rates were highest in those living in most deprived areas, with a strong social gradient. Asian-born mothers had highest GDM rates. All migrant groups except women born in North-West Europe had higher odds of GDM than Australian-born non-Indigenous women. In all ethnic groups, these differences were not pronounced among younger mothers, but became increasingly apparent amongst older women. Conclusions Socio-cultural disparities in GDM burden differ by maternal age at first delivery. Socio-cultural gradients were not evident among younger women. Health and social programs should seek to reduce the risk amongst all older women to that of the least deprived older mothers.

Objectives This paper reports secular trends in diabetes in pregnancy in Victoria, Australia and examines the effect of including or excluding women with pre-existing diabetes on gestational diabetes (GDM) prevalence estimates. Design Population-based observational study. Setting All births in Victoria, Australia between 1999 and 2008 Participants 634 932 pregnancies resulting in a birth registered with the Victorian Perinatal Data Collection Outcome measures Crude and age-standardised secular trends in pre-existing diabetes and GDM prevalence; secular GDM trends by maternal birthplace; effects on GDM prevalence of including and excluding pre-existing diabetes from the denominator. Results Of the 634 932 pregnancies, 2954 (0.5%) occurred in women with pre-existing diabetes and 29 147 (4.6%) were complicated by GDM. Mean maternal age increased from 29.7 years in 1999 to 30.8 years in 2008. GDM prevalence increased in most maternal age groups. In 2008, age-standardised GDM prevalence was 31% higher than in 1999; secular increases were greater for Australian-born non-Indigenous (29% increase) than immigrant women (12.3% increase). The annual number of pregnancies in women with pre-existing diabetes almost doubled from 1999 to 2008 and prevalence increased from 0.4% to 0.6%. However, including or excluding pre-existing diabetes had little effect on GDM prevalence estimates. Conclusions Pre-existing diabetes and GDM prevalence increased in Victoria between 1999 and 2008 and rising maternal age does not fully explain these trends. These findings have important implications for preventive initiatives. Including or excluding small numbers of women with pre-existing diabetes resulted in minimal changes in GDM estimates. As pre-existing diabetes in young women increases, this methodological issue will likely become important.

Background Pregnant women who have previously had a caesarean birth and who have no contraindication for vaginal birth after caesarean (VBAC) may need to decide whether to choose between a repeat caesarean birth or to commence labour with the intention of achieving a VBAC. Women need information about their options and interventions designed to support decision-making may be helpful. Decision support interventions can be implemented independently, or shared with health professionals during clinical encounters or used in mediated social encounters with others, such as telephone decision coaching services. Decision support interventions can include decision aids, one-on-one counselling, group information or support sessions and decision protocols or algorithms. This review considers any decision support intervention for pregnant women making birth choices after a previous caesarean birth. Objectives To examine the effectiveness of interventions to support decision-making about vaginal birth after a caesarean birth. Secondary objectives are to identify issues related to the acceptability of any interventions to parents and the feasibility of their implementation. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2013), Current Controlled Trials (22 July 2013), the WHO International Clinical Trials Registry Platform Search Portal (ICTRP) (22 July 2013) and reference lists of retrieved articles. We also conducted citation searches of included studies to identify possible concurrent qualitative studies. Selection criteria All published, unpublished, and ongoing randomised controlled trials (RCTs) and quasi-randomised trials with reported data of any intervention designed to support pregnant women who have previously had a caesarean birth make decisions about their options for birth. Studies using a cluster-randomised design were eligible for inclusion but none were identified. Studies using a cross-over design were not eligible for inclusion. Studies published in abstract form only would have been eligible for inclusion if data were able to be extracted. Data collection and analysis Two review authors independently applied the selection criteria and carried out data extraction and quality assessment of studies. Data were checked for accuracy. We contacted authors of included trials for additional information. All included interventions were classified as independent, shared or mediated decision supports. Consensus was obtained for classifications. Verification of the final list of included studies was undertaken by three review authors. Main results Three randomised controlled trials involving 2270 women from high-income countries were eligible for inclusion in the review. Outcomes were reported for 1280 infants in one study. The interventions assessed in the trials were designed to be used either independently by women or mediated through the involvement of independent support. No studies looked at shared decision supports, that is, interventions designed to facilitate shared decision-making with health professionals during clinical encounters. We found no difference in planned mode of birth: VBAC (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.97 to 1.10; I² = 0%) or caesarean birth (RR 0.96, 95% CI 0.84 to 1.10; I² = 0%). The proportion of women unsure about preference did not change (RR 0.87, 95% CI 0.62 to 1.20; I² = 0%). There was no difference in adverse outcomes reported between intervention and control groups (one trial, 1275 women/1280 babies): permanent (RR 0.66, 95% CI 0.32 to 1.36); severe (RR 1.02, 95% CI 0.77 to 1.36); unclear (0.66, 95% CI 0.27, 1.61). Overall, 64.8% of those indicating preference for VBAC achieved it, while 97.1% of those planning caesarean birth achieved this mode of birth. We found no difference in the proportion of women achieving congruence between preferred and actual mode of birth (RR 1.02, 95% CI 0.96 to 1.07) (three trials, 1921 women). More women had caesarean births (57.3%), including 535 women where it was unplanned (42.6% all caesarean deliveries and 24.4% all births). We found no difference in actual mode of birth between groups, (average RR 0.97, 95% CI 0.89 to 1.06) (three trials, 2190 women). Decisional conflict about preferred mode of birth was lower (less uncertainty) for women with decisional support (standardised mean difference (SMD) -0.25, 95% CI -0.47 to -0.02; two trials, 787 women; I² = 48%). There was also a significant increase in knowledge among women with decision support compared with those in the control group (SMD 0.74, 95% CI 0.46 to 1.03; two trials, 787 women; I² = 65%). However, there was considerable heterogeneity between the two studies contributing to this outcome ( I² = 65%) and attrition was greater than 15 per cent and the evidence for this outcome is considered to be moderate quality only. There was no difference in satisfaction between women with decision support and those without it (SMD 0.06, 95% CI -0.09 to 0.20; two trials, 797 women; I² = 0%). No study assessed decisional regret or whether women's information needs were met. Qualitative data gathered in interviews with women and health professionals provided information about acceptability of the decision support and its feasibility of implementation. While women liked the decision support there was concern among health professionals about their impact on their time and workload. Authors' conclusions Evidence is limited to independent and mediated decision supports. Research is needed on shared decision support interventions for women considering mode of birth in a pregnancy after a caesarean birth to use with their care providers.

Detection of abnormal fetal growth is vital to antenatal care, and traditionally birthweights that are10th or90th centile are classified as small or large for gestational age (LGA). Evidence regarding outcomes for birthweight centiles outside these extremes remains unclear.To evaluate the relationship between birthweight centile and perinatal death and determine the 'optimum' birthweight centile with the lowest rate of perinatal mortality.Data on all Victorian births from 1999 to 2008 were stratified into smaller subsets than the traditional small for gestational age (SGA) (10th centile), appropriate for gestational age (AGA) (10-90th centile) and LGA (90th centile) and analysed by all gestations, for term births alone, and using the 'fetus at risk' approach. Multiple logistic regression was used to adjust for age, parity and co-morbidities.For term births, the 'optimum' birthweight centile was the 50-90th range (1.1 perinatal deaths/1000 births). Lower birthweight centiles had significantly higher rates of perinatal death - even those that would be classified as AGA. Babies with a 10-25th birthweight centile had a two-fold increased risk of perinatal death (AOR 2.10, 95% CI 1.6, 2.7). Even those with a 25-50th birthweight centile had higher perinatal mortality rates (AOR 1.58, 95% CI 1.3, 2.0). There was no strong evidence of higher perinatal mortality in larger birthweight centiles, except term births99th centile. The 'fetus at risk' analysis showed a rise in perinatal mortality after 37 weeks' gestation for all birthweight centiles, particularly for SGA babies.Babies with a birthweight below the 50th centile are at greater risk of perinatal mortality compared with the 'optimum' ≥50 to90th centile group.

Objective to explore the relationship between the degree to which labour is established on admission to hospital and method of birth. Background a recent randomised controlled trial found fewer caesarean sections (CS) in women allocated to caseload midwifery (19.4%) compared with standard care (24.9%). There is interest in exploring what specific aspects of the care might have resulted in this reduction. Setting a large tertiary-level maternity service in Melbourne, Australia. Participants English-speaking women with no previous caesarean section at low risk of complications in pregnancy were recruited to a randomised controlled trial. Trial participants whose management did not include a planned caesarean and who were admitted to hospital in spontaneous labour were included in this secondary analysis of trial data ( n =1532). Methods this secondary analysis included women admitted to hospital in spontaneous labour who were randomised to caseload midwifery compared with those randomised to standard care with regard to timing of admission in labour, augmentation of labour and use of epidural analgesia. In a further analysis randomised groups were pooled to examine predictors of caesarean section for first births only using multiple logistic regression. Results nulliparous women randomised to standard care were more likely to have labour augmented than those having caseload care (54.2% and 45.5% respectively, p =0.008), but were no more likely to use epidural analgesia. They were admitted earlier in labour, spending 1.1 hours longer than those in the caseload arm in hospital before the birth ( p =0.003). Parous women allocated to standard care were more likely than those in the caseload arm to use epidural analgesia (10.0% and 5.3% respectively, p =0.047), but were no more likely to have labour augmented. They were also admitted earlier in labour, with a median cervical dilatation of 4cm compared with 5cm in the caseload arm ( p =0.012). Pooling the two randomised groups of nulliparous women, and after adjusting for randomised group, maternal age and maternal body mass index, early admission to hospital was strongly associated with caesarean section. Admission before the cervix was 5cm dilated increased the odds 2.4-fold (95%CI 1.4, 4.0; p =0.001). Augmentation of labour and use of epidural analgesia were each strongly associated with caesarean section (adjusted odds ratios 3.10 (95%CI 2.1, 4.5) and 5.77 (95%CI 4.0, 8.4) respectively. Conclusion these findings that women allocated to caseload care were admitted to hospital later in labour, and that earlier admission was strongly associated with birth by caesarean section, suggest that remaining at home somewhat longer in labour may be one of the mechanisms by which caseload care was effective in reducing caesarean section in the COSMOS trial.

women have consistently rated postnatal care less favourably than other episodes of maternity care. Midwives have also reported concerns with postnatal care, with challenges related to workloads, busy environments and lack of staff. Given these concerns, a regional hospital in Victoria, Australia redesigned its postnatal care provision. The changes included cessation of routine postnatal observations and the use of clinical pathways for women who gave birth vaginally; promotion of rest through minimal disturbances before 9 am; discouraging the use of the call bell system except in emergency situations; introduction of 'one-to-one' time with women; and promotion of normalcy and independence. This paper examines midwives' views of the changes and their impressions of the effects of the changes on women and their infants.cross-sectional surveys of midwives were conducted six months after the changes to postnatal care were introduced then again, two years later. Midwives' views and experiences of the changes; the impact of the changes on confidence and autonomy of practice; views regarding the effect on women's satisfaction with care; and the perceived safety of the changes were explored.a regional hospital in Victoria, Australia where approximately 2,000 births occur each year.permanent part-time and full-time midwives.response rates were 64% (50/78) at baseline and 60% (50/84) two years later. Overall, midwives were supportive of, and complied with, the changes to postnatal care. They agreed that change was needed and believed that the new way of providing care would be better for women and increase individualised care. Midwives also agreed that the changes would facilitate rest for women, believed that removal of routine observations for women after a vaginal birth was safe and that it would allow more time with women. Over time, midwives were more likely to feel autonomous when providing postnatal care. However, some concerns were raised, mostly in relation to the challenges around postnatal documentation, care provision without the guidance of a care/clinical pathway, and about limiting the use of the call bell to only emergency situations. Midwives were not confident that the changes would necessarily translate to a measurable increase in women's satisfaction with care, and were not confident that the changes translated into more time to spend listening and providing support to women.overall, midwives were supportive of the changes and agreed that change to postnatal care was needed. Challenges remain around the most effective method of communication and documentation of postnatal care. It is important that when major changes to care provision are implemented that care providers' views and experiences are explored given their crucial role in the introduction and maintenance of changes and the potential impact on them as care providers.

in Australia, and globally, rates for gestational diabetes mellitus (GDM) have risen dramatically in recent decades. This is of concern as GDM is associated with adverse pregnancy outcomes and additional health-care costs. Factors linked to increasing incidence include older maternal age and non-Caucasian ethnicity. However, as yet, there is no clear consensus on the magnitude of effect associated with these factors in combination. This study therefore investigated the effect of maternal age and country/region of birth on GDM incidence.all women who gave birth in Victoria, Australia in 2005 and 2006 (n=133,359) were included in this population-based cross-sectional study. Stratified cross-tabulations were conducted to examine the incidence of GDM by maternal age group and country/region of birth. Primiparous women were further analysed separately from parous women. The proportion of women with GDM was reported, along with the χ(2) for linear trend.whilst women born outside Australia constituted just 24.6% of women giving birth during the study period, they accounted for 41.4% of GDM cases. The highest GDM incidence was seen among Asian women at 11.5%, compared with Australian born women at 3.7%. There was strong evidence that women born in all regions except North America were increasingly likely to develop GDM in pregnancies at older ages (p0.001).On examining age related GDM trends by maternal region of birth, higher rates were seen across all regions studied but were most marked among women born in Asia and the Middle East.older maternal age and non-Australian birth increased a woman's risk of developing GDM and this increase was most evident among Asian women. As GDM is associated with adverse maternal and infant outcomes, it is important to explore ways of preventing GDM, and to put in place strategies to effectively manage GDM during pregnancy and to reduce the later risk of developing type 2 diabetes. Pregnancy presents midwives with a unique opportunity to provide education and to encourage dietary and behavioural modifications as women have repeated contact with the health system during this time.

Background: In Australia, birth rates for women aged 35 years or more are significant and increasing and a considerable percentage are first births. This study investigated the effect of maternal age on interventions in labor and birth for primiparous women aged 35 to 44 years compared with primiparous women aged 25 to 29 years. Methods: All primiparous women who gave birth in Victoria, Australia, in 2005 and 2006 (n = 57,426) were included in this population-based cross-sectional study. Women were stratified by admission status (private/public). Main outcome measures were induction of labor, augmentation of labor, use of epidural analgesia, and method of birth. Multivariate logistic regression was used to explore the relationship between maternal age and cesarean adjusted for confounders. Results: Older women were more likely to give birth by cesarean section whether admitted as public or private patients. For private patients, total cesarean rates were 31.8 percent (25–29 yr), 46.0 percent (35–39 yr), and 60.0 percent (40–44 yr; p < 0.001) compared with 27.5, 41.6, and 53.4 percent for public patients (p < 0.001). Older women who experienced labor were more likely to have an instrumental vaginal birth or an emergency cesarean section than younger women. Both were more common in women admitted as private patients. Age-related trends were also seen for induction of labor and use of epidural analgesia. Rates were higher for private patients. Rates of induction were (37.8, 40.2, and 42.5%) for private patients compared with (32.1, 36.7, and 40.1%) for public patients and rates for epidural were (45.3, 49.9, and 48.1%) among private patients compared with (33.3, 38.8, and 39.3%) among public patients. Conclusions: Interventions in labor and birth increased with maternal age, and this effect was seen particularly for cesarean section among women admitted privately. These findings were not fully explained by the complications we considered.

Objectives:To determine the proportion of women who took folate supplementation prior to conception and in the first three months of pregnancy and/or increased folate dietary intake; to determine how folate supplementation varied with socio-demographic factors; and to describe the ways women had seen or heard about folate prior to pregnancy. Methods:Two population-based surveys were used: the Victorian Survey of Recent Mothers 2000 and the 2001 NSW Child Health Survey. Results:Thirty-six per cent of women in Victoria reported taking periconceptional folate supplements compared with 46% in NSW. In Victoria, 8%, and in NSW, 28% of women had increased dietary folate intake. In both surveys younger women, women with less education, less income, of non-English speaking background and women who were not married were less likely to take folate supplements in the recommended period. In Victoria, multiparous women were significantly less likely to take supplements. In NSW, women with an unplanned pregnancy and those living in rural areas were significantly less likely to take periconceptional folate supplements. Fifty-three per cent of women cited a general practitioner or obstetrician as a source of folate information and 45% cited family or friends; both of these sources were significantly associated with periconceptional folate supplementation. Conclusions:Less than 50% of women took periconceptional folate supplements. Among socially disadvantaged groups, the proportion was significantly lower. Implications:Since women are unlikely to achieve adequate folate intake periconceptionally without deliberate action, there remains the need for a multifaceted approach to providing women with information about folate. Future surveys are needed to monitor usage and knowledge.

BACKGROUND: Continuity of care and of caregiver are thought to be important influences on women's experience of maternity care. The aim of this study was to analyze the influence of two aspects of continuity of caregiver in the antenatal period on women's overall rating of antenatal care: the extent to which women saw the same caregiver throughout pregnancy, and the extent to which women thought that their caregiver knew and remembered them and their progress from one visit to the next. METHODS: An anonymous, population-based postal survey was conducted of 1,616 women who gave birth in a 14-day period in September 1999 in Victoria, Australia. Multivariate methods were used to analyze the data. RESULTS: Most women saw the same caregiver at each antenatal visit (77%), and thought that caregivers got to know them (65%). This finding varied widely among different models of maternity care. Before adjustment, women were much more likely to describe their antenatal care as very good if they always or mostly thought the caregiver got to know them (OR 5.86, 95% CI 4.3, 7.9), and if they always or mostly saw the same caregiver at each visit (OR 2.91, 95% CI 2.0, 4.3). Adjusting for sociodemographic factors, parity, risk status of the pregnancy, and several specific aspects of antenatal care revealed that seeing the same caregiver was no longer associated with rating of care (adjusted OR 0.65, 95% CI 0.3,1.2), but women who thought that caregivers got to know and remember them remained much more likely to rate their care highly (adjusted OR 3.18, 95% CI 2.0, 5.1). CONCLUSIONS: These findings suggest that changing the delivery of antenatal care to increase women's chances of seeing the same caregiver at each visit is not by itself likely to improve the overall experience of care, but time spent personalizing each encounter in antenatal care would be well received. The analysis also confirmed the importance that women place on quality interactions with their doctors and midwives.

Introduction: Tertiary maternity services in Western countries are framed in pathogenesis creating a culture of riskmagnification, a sceptical view of labour physiology, a low threshold for labour intervention and increasing rates of caesarean section. The theory of salutogenesis offers an alternative as it focuses on the causes of health rather than the causes of illness. Sense of coherence (SOC), the cornerstone of salutogenic theory, is a predictive indicator of health. Aim: To investigate the relationship between a pregnant woman’s SOC, the childbirth choices she made in pregnancy and her birthing outcomes. Methods: A cross sectional survey was conducted in the ACT where eligible women completed a questionnaire at two time points, one antenatal and one postnatal. The questionnaires provided information on SOC scores, Edinburgh Postnatal Depression (EPDS) scores, Support Behaviour Inventory (SBI) scores, pregnancy choices, birth outcomes and demographics. Results: The first questionnaire was completed by 1074 women and a 75% return rate was achieved on the second questionnaire. Compared to women with low SOC, women with high SOC were less likely to birth by caesarean section, more likely to experience an assisted vaginal birth, were older, were less likely to identify pregnancy conditions, had lower EPDS scores and higher SBI scores. SOC was not associated with women’s pregnancy choices. Conclusion: In this population, pregnant women with high SOC have fewer caesarean sections compared to women with low SOC. SOC is an important predictor of women’s childbearing health and attention should be focused on increasing women’s SOC in the antenatal period through antenatal care and education. More research is required to relate salutogenesis in general, and SOC in particular, to childbearing women.