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Background Birth is a significant event in women’s lives. Many women aim for a birth that avoids pharmacological pain relief because they are advised it is better for them and their baby. For women having their first baby, this may not be realistic as 3/4 of primiparous women in Australia will use pharmacological pain relief. This study examines the expectations that a group of women had regarding pain relief, how these expectations developed and what happened to their requests for pain relief in labour. Methods A longitudinal prospective study design was used to recruit 15 women who were having their first baby. Women having low risk pregnancies, hoping for a ‘natural birth’ (vaginal, no/minimal pharmacological pain relief) were eligible. A semi-structured interview tool was used across all three interviews that asked women about their expectations, then actual labour experience, pain management requests and how these were responded to by carers. Women were interviewed three times – at 36 weeks gestation; as soon after delivery of their baby as possible, then six months post-delivery (N = 43 interviews). Interviews were recorded and transcribed and coded by ES using NVivo software with hierarchical thematic analysis used. Results The study found that women appear to experience a mismatch between expectations they have developed pre-birth, versus actual experience. This appears to cause a specific form of dissonance – which we have termed ‘birth dissonance’ leaving them feeling traumatised post birth. This is because what women expected to happen in birth was often not realised. In particular, when women request pain relief in birth and that request is not responded to as hoped, women are more likely to develop post-birth trauma as a result of this dissonance arising from their expectations about birth being able to be done without significant pain relief. Interventions and technology may also contribute to this sense of mismatch and post-birth trauma. Conclusions Low risk birthing women delivering in a hospital may have to engage with higher levels of technology, intervention and pain relief than that which they expected pre-birth. This could possibly be avoided with four simple changes. Firstly, better pre-birth education for women about how painful labor is likely to be. Secondly, pre-birth education which includes a detailed explanation of the utility of pain relief and that new evidence shows epidurals do not lead to higher rates of interventions or surgical births. Thirdly, more egalitarian decision-making during labour, and finally delivering upon women’s requests for pain relief in labor, at the time that they ask for it. Further research is required to determine the extent of birth dissonance and how women making the transition to motherhood can avoid it.

Background Women of refugee background may be particularly vulnerable to perinatal mental illness, possibly due to increased exposure to psychosocial stressors associated with their forced migration and post-resettlement adjustment. Aim This study aimed to compare psychosocial risk factors reported by women of refugee background receiving maternity services at a public hospital, to those reported by Australian-born women in the same hospital. It further aimed to examine the referrals offered, and accepted, by the women of refugee background reporting psychosocial risk factors for perinatal mental illness. Methods A retrospective hospital record review was conducted to compare the antenatal and postnatal psychosocial risk factors of 100 women of refugee background and 100 Australian-born women who gave birth at a public hospital in Victoria between 1 July 2015 and 30 April 2016, and who had completed the Maternity Psychosocial Needs Assessment. Findings Women of refugee background were more likely than Australian-born women to report financial concerns and low social support at antenatal assessment, but were less likely to report prior mental health problems than Australian-born women at either assessment point. Both groups reported low rates of family violence compared to published prevalence rates. Of the women of refugee background assessed antenatally, 23% were offered referrals, with 52% take-up. Postnatally, 11.2% were offered referrals, with 93% take-up. Discussion/conclusion This study showed elevated rates of psychosocial risk factors among women of refugee background, however, possible under-reporting of mental health problems and family violence raises questions regarding how to assess psychosocial risk factors with different cultural groups. Lower antenatal referral take-up suggests barriers to acceptance of referrals may exist during pregnancy.

Problem National guidelines recommend repeated screening for depression and anxiety for all women in the perinatal period. Routine screening in pregnancy is limited due to service, community and individual barriers. Background Perinatal depression and perinatal anxiety affect up to 20% of all women. Women of refugee background are at even greater risk for perinatal mental health conditions due to refugee experiences and resettlement stressors. Aim To evaluate the acceptability and feasibility of a perinatal mental health screening program for women of refugee background from the perspective of health professionals. Methods A mixed methods design guided by the Normalization Process Theory was used. Data were collected at a dedicated refugee antenatal clinic in the south-eastern suburbs of Melbourne, Australia. An online survey (n = 38), focus groups (n = 2; 13 participants) and semi-structured interviews (n = 8; 11 participants) with health professionals were conducted. Findings Under the four constructs of the Normalization Process Theory, health professionals reported improvements in identifying and referring women with mental health issues, more open and in-depth conversations with women about mental health and valued using an evidenced-based measure. Key issues included professional development, language barriers and time constraints. Discussion Implementing a perinatal mental health screening program has been positively received. Strategies for sustainability include professional development and the addition of audio versions of the measures. Conclusion This perinatal mental health screening program is acceptable and a feasible option for health professionals. Health professionals value providing more holistic care and have more open discussion with women about mental health.

A previous article sought to signpost papers that were considered helpful when starting on the journey of practicing evidence-based medicine (EBM).1 The lead author was invited to run a workshop at the Eighth Conference of the International Society for Evidence-Based Health Care run in collaboration with the Gruppo Italiano per la Medicina Basata sulle Evidenze from 6 November to 9 November 2019. The aim of the workshop was to challenge a group of teachers and educators to consider useful papers for the teaching of EBM/evidence-based healthcare (EBHC). The second aim was to start a database of such studies. The third aim was to share learning and foster discussion from the workshop through journal publication. EBM and EBHC are used interchangeable throughout this article. Working in eight small groups (three to five people), teachers and researchers of EBM/EBHC (n=29) first listed any articles that they considered useful for new teachers starting out their teaching journey. So that the challenge also acted as learning for the participants, they were deliberately not briefed on the full nature of the workshop (eg, the consideration and selection of specific articles). After 15 min, each group spent another 10 min selecting their top three articles from their original list (if this list had more than three papers). This was followed by another 5 min selecting their final article to put forward for this paper consensus and any disagreements resolved via discussion. Groups had to provide the following information for each paper: authors; year of publication; title; reason(s) for inclusion; link to paper/reference. Learning from previous experiences, the workshop lead (DN) instructed that a group could not select an article for which a group member was an author thus avoiding one possible source of conflict. As a group we felt that this specific rule of the article selection process …

IntroductionPregnancy and early parenthood are key opportunities for interaction with health services and connecting to other families at the same life stage. Public antenatal care should be accessible to all, however barriers persist for families from refugee communities to access, navigate and optimise healthcare during pregnancy. Group Pregnancy Care is an innovative model of care codesigned with a community from a refugee background and other key stakeholders in Melbourne, Australia. Group Pregnancy Care aims to provide a culturally safe and supportive environment for women to participate in antenatal care in a language they understand, to improve health literacy and promote social connections and inclusion. This paper outlines Froup Pregnancy Care and provides details of the evaluation framework.Methods and analysisThe evaluation uses community-based participatory research methods to engage stakeholders in codesign of evaluation methods. The study is being conducted across multiple sites and involves multiple phases, use of quantitative and qualitative methods, and an interrupted time series design. Process and cost-effectiveness measures will be incorporated into quality improvement cycles. Evaluation measures will be developed using codesign and participatory principles informed by community and stakeholder engagement and will be piloted prior to implementation.Ethics and disseminationEthics approvals have been provided by all six relevant authorities. Study findings will be shared with communities and stakeholders via agreed pathways including community forums, partnership meetings, conferences, policy and practice briefs and journal articles. Dissemination activities will be developed using codesign and participatory principles.

Preeclampsia (PE) can suddenly disrupt a normal pregnancy experience. This project aimed to see how PE was experienced close to the time of birth, in a group of hospital patients. Women with PE who gave birth at The Royal Women's Hospital, Melbourne, Australia, from October 2010 to May 2012 were asked to complete a survey designed with consumer input. There was a 74% response rate. Regarding diagnosis, 90% experienced PE, 2.5% experienced eclampsia and 7.5% experienced HELLP. For 60% of women, their baby was born earlier than expected. Although 67.5% of women knew little about PE prior to pregnancy and diagnosis, 67.5% believed PE was serious or life threatening. Fifty-five percent were afraid that their baby might die. The women in the study identified the need to obtain more information about PE (97.5%), and 60% indicated that their PE experience would either delay or contribute to the decision to not undertake a future pregnancy. This project details that PE can have a substantial psychological effect on patients around the time of birth. Maternity caregivers can direct counselling to address the specific vulnerabilities raised in PE and thus improve the care of women with PE.Impact StatementWhat is already known on this subject? Qualitative research from New Zealand showed that women experiencing preeclampsia (PE) can have a number of psychological issues with their pregnancy experience, including feeling no longer in control of their pregnancy, dealing with an unexpected medicalised preterm birth, and feeling fear for themselves and their baby's life, even if no formal psychiatric issues are identified. A PE support group surveyed their own members and found that these psychological issues are present in most of their members who had PE.What the results of this study add? This study was a survey of 40 women experiencing PE around the time of birth in a tertiary hospital in Melbourne, Australia, to see if these themes could be applied to a general hospital group. There was a 74% response rate. For 60% of women, the baby was born earlier than expected. Although most women knew little about PE prior to diagnosis, 67.5% believed PE was serious or life threatening at diagnosis. More than half (55%) were afraid their baby might die and 47.5% of women identified that separation from their baby impaired their ability to bond. Most women planned to obtain more information about PE (97.5%) and 50% indicated that their PE experience meant they would either delay or not undertake future pregnancy.What the implications are of these findings for clinical practice and/or further clinical research? This study demonstrates the significance of psychological factors in the care of women with pre-eclampsia or eclampsia and offers a range of issues that the health care provider can use in discussions with women in the early postnatal period, in the inter-pregnancy interval and in subsequent pregnancies. Further research would ideally involve a large sample in a range of hospital settings (primary through tertiary) to further consider the prevalence and enduring nature of themes identified in the present study.

Objective The My Baby’s Movements (MBM) trial aimed to evaluate the impact on stillbirth rates of a multifaceted awareness package (MBM intervention). Design Stepped-wedge cluster-randomised controlled trial. Setting Twenty-seven maternity hospitals in Australia and New Zealand. Population Women with a singleton pregnancy without major fetal anomaly ≥28 weeks’ gestation from August 2016-May 2019. Methods The MBM intervention was implemented at randomly assigned time points with sequential introduction into 8 clusters of 3-5 hospitals at four-monthly intervals. The stillbirth rate was compared in the control and intervention periods. Generalised linear mixed models controlled for calendar time, clustering, and hospital effects. Outcome Measures Stillbirth at ≥28 weeks’ gestation. Results There were 304,853 births with 290,219 meeting inclusion criteria: 150,079 in control and 140,140 in intervention periods. The stillbirth rate during the intervention was lower than the control period (2.2/1000 births versus 2.4, odds ratio [OR] 0.91, 95% Confidence Intervals [CI] 0.78-1.06, p=0.22). The decrease was larger across calendar time with 2.7/1000 in the first 18 months versus 2.0/1000 in the last 18 months (OR 0.74; 95% CI 0.63-0.86; p≤0.01). Following adjustment, stillbirth rates between the control and intervention periods were not significantly different: (aOR 1.18, 95% CI 0.93-1.50; p=0.18). No increase in secondary outcomes, including obstetric intervention or adverse neonatal outcome, was evident. Conclusion The MBM intervention did not reduce stillbirths beyond the downward trend over time, suggesting hospitals may have implemented best practice in DFM management outside their randomisation schedule. The role of interventions for raising awareness of DFM remains unclear

Background and objective Significant health care resources are allocated to monitoring high risk pregnancies to minimize growth compromise, reduce morbidity and prevent stillbirth. Fetal movement has been recognized as an important indicator of fetal health. Studies have shown that 25% of pregnancies with decreased fetal movement in the third trimester led to poor outcomes at birth. The studies have also shown that maternal perception of fetal movement is highly subjective and varies from person to person. A non-invasive system for fetal movement detection that can be used outside hospital would represent an advance in at-home monitoring of at-risk pregnancies. This is a challenging task that requires the use of advanced signal processing techniques to differentiate genuine fetal movements from contaminating artefacts. Methods This manuscript proposes a novel algorithm for automatic fetal movement recognition using data collected from wearable tri-axial accelerometers strategically placed on the maternal abdomen. The novelty of the work resides in the efficient removal of artefacts and in distinctive feature extraction. The proposed algorithm used independent component analysis (ICA) for dimensionality reduction and artefact removal. A supplemental technique based on discrete wavelet transform (DWT) was also used to remove artefacts. Results To identify fetal movements, 31 features were extracted from the acceleration data. Based on these features, several classifiers were used to distinguish fetal from non-fetal movements. Robustness of the classifiers was tested for various concentrations of artefacts in the classification data. The best performance was achieved by Bagging classifier algorithm, with random forest as its basis classifier, yielding an accuracy ranging from 87.6% to 95.8% depending on the artefact concentration level. Conclusions A high performance detection of fetal movements can be achieved using accelerometery-based systems suitable for long-term monitoring.

Background: Maternal perception of decreased fetal movements (DFM) is associated with stillbirth. The My Baby’s Movements (MBM) trial aimed to evaluate the impact on stillbirth rates of a multifaceted awareness package for women and clinicians. Methods: A stepped wedge cluster randomised controlled trial was undertaken with 8 groups of 3-5 hospitals in Australia and New Zealand at four-monthly intervals, targeting women with a singleton pregnancy without major fetal anomaly at ≥28 weeks’ gestation. The primary outcome was stillbirth at ≥28 weeks’ gestation. Secondary outcomes included obstetric and neonatal outcomes. Analysis was undertaken using generalised linear mixed models controlling for calendar time, clustering, and hospital effects. Findings: From August 2016 to May 2019 there were 304,853 births with 290,219 meeting inclusion criteria: 150,079 in control and 140,140 in intervention periods. The stillbirth rate during the intervention was lower than the control period, although not statistically significant (2·2/1000 births versus 2·4, odds ratio [OR] 0·91, 95% Confidence Intervals [CI] 0·78-1·06, p=0·22). The decrease was larger across calendar time with 2·7/1000 in the first 18 months versus 2·0/1000 in the last 18 months (OR 0·74; 95% CI 0·63-0·86; p≤0·01). Adjusting for calendar time, stillbirth rates between the control and intervention periods were not significantly different: (aOR 1·18, 95% CI 0·93-1·50; p=0·18). No increase in obstetric intervention or adverse neonatal outcome was evident. Interpretation: The MBM intervention did not reduce stillbirths beyond the downward trend over time, suggesting hospitals may have implemented best practice in DFM management outside their randomisation schedule. Based on these findings, the role of interventions for raising awareness of DFM remains unclear. Trial Registration: ACTRN12614000291684. Funding Statement: National Health and Medical Research Council (NHMRC) Project Grant Application (APP1067363). Stillbirth Foundation Australia provided funding to develop the MBM application. Dr Glenn Gardener was provided a Betty McGrath Fellowship through the Mater Research Institute. Additional support was provided by Mater Foundation and the NHMRC Stillbirth Centre of Research Excellence. Declaration of Interests: The authors declare that they have no competing interests. Ethics Approval Statement: Primary ethics approval was obtained from Mater Misericordiae Ltd Human Research Ethics Committee (EC00332) (MML HREC) in 2015. Further jurisdictional ethics approval was obtained from seven participating HRECs include the ACT Health, Northern Sydney Local Health District (NSLHD), Northern Territory Department of Health and Menzies School of Health Research, The Central Health and Disability Ethics Committee (NZ), Melbourne Health, and the Mercy Health. Governance clearance was obtained from all 26 sites involved in the trial.

Background Preterm infants and neonates with respiratory conditions commonly require intubation and conventional mechanical ventilation (CMV) to maintain airway patency and support their respiration. Whilst this therapy is often lifesaving, it simultaneously carries the risk of lung injury. The use of lung recruitment manoeuvres (LRMs) has been found to reduce the incidence of lung injury, and improve oxygenation and lung compliance in ventilated adults. However, evidence pertaining to their use in neonates is limited, and there is no consensus of opinion as to whether LRMs are appropriate or effective in this population. Objectives To determine the effects of LRMs on mortality and respiratory outcomes in mechanically ventilated neonates, when compared to no recruitment (routine care). Search methods We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2020, Issue 4) in the Cochrane Library, MEDLINE via Ovid (1946 to 13 April 2020), and CINAHL via EBSCOhost (1989 to 13 April 2020). We also handsearched the reference lists of retrieved studies to source additional articles. Selection criteria We included randomised controlled trials (RCTs), quasi‐RCTs and randomised cross‐over studies that compared the effect of LRMs to no recruitment (routine care) in mechanically ventilated neonates. Data collection and analysis Two review authors independently assessed trial eligibility, extracted data and evaluated risk of bias in the included studies. When studies were sufficiently similar, we performed a meta‐analysis using mean difference (MD) for continuous data and risk ratio (RR) for dichotomous data, with their respective 95% confidence intervals (CIs). We used the GRADE approach to assess the certainty of the evidence for key (clinically important) outcomes. Main results We included four studies (152 participants in total) in this review. Three of these studies, enrolling 56 participants, contributed data to our prespecified outcomes. Two studies enrolling 44 participants on CMV for respiratory distress syndrome compared a stepwise LRM with positive end‐expiratory pressure (PEEP) to routine care. Meta‐analysis demonstrated no evidence of a difference between the LRM and routine care on mortality by hospital discharge (RR 1.00, 95% CI 0.17 to 5.77; low‐certainty evidence), incidence of bronchopulmonary dysplasia (RR 0.25, 95% CI 0.03 to 2.07; low‐certainty evidence), duration of supplemental oxygen (MD ‐7.52 days, 95% CI ‐20.83 to 5.78; very low‐certainty evidence), and duration of ventilatory support (MD ‐3.59 days, 95% CI ‐12.97 to 5.79; very low‐certainty evidence). The certainty of the evidence for these outcomes was downgraded due to risk of bias, imprecision, and inconsistency. Whilst these studies contributed data to four of our primary outcomes, we were unable to identify any studies that reported our other primary outcomes: duration of continuous positive airway pressure therapy, duration of neonatal intensive care unit stay, and duration of hospital stay. The third study that contributed data to the review enrolled 12 participants on CMV for respiratory and non‐respiratory causes, and compared two different LRMs applied after endotracheal tube suctioning to routine care. It was determined that both LRMs may slightly improve end‐expiratory lung volume at 120 minutes' post‐suctioning, when compared to routine care (incremental PEEP LRM versus routine care: MD ‐0.21, 95% CI ‐0.37 to ‐0.06; double PEEP LRM versus routine care: MD ‐0.18, 95% CI ‐0.35 to ‐0.02). It was also demonstrated that a double PEEP LRM may slightly reduce mean arterial pressure at 30 minutes' post‐suctioning, when compared with routine care (MD ‐16.00, 95% CI ‐29.35 to ‐2.65). Authors' conclusions There is insufficient evidence to guide the use of LRMs in mechanically ventilated neonates. Well‐designed randomised trials with larger sample sizes are needed to further evaluate the potential benefits and risks of LRM application in this population.

BACKGROUND Simulation-based programs are increasingly being used to teach obstetrics and gynaecology examinations, but it is difficult to establish student learning acquired through them. Assessment may test student learning but its role in learning itself is rarely recognised. We undertook this study to assess medical and midwifery student learning through a simulation program using a pre-test and post-test design and also to evaluate use of assessment as a method of learning. METHODS The interprofessional simulation education program consisted of a brief pre-reading document, a lecture, a video demonstration and a hands-on workshop. Over a 24-month period, 405 medical and 104 midwifery students participated in the study and were assessed before and after the program. Numerical data were analysed using paired t-test and one-way analysis of variance. Students' perceptions of the role of assessment in learning were qualitatively analysed. RESULTS The post-test scores were significantly higher than the pre-test (P

Infants of women with diabetes in pregnancy are at increased risk of hypoglycaemia, admission to a neonatal intensive care unit (NICU), and not being exclusively breastfed. Many clinicians encourage women with diabetes in pregnancy to express and store breastmilk in late pregnancy, yet no evidence exists for this practice. We aimed to determine the safety and efficacy of antenatal expressing in women with diabetes in pregnancy.We did a multicentre, two-group, unblinded, randomised controlled trial in six hospitals in Victoria, Australia. We recruited women with pre-existing or gestational diabetes in a singleton pregnancy from 34 to 37 weeks' gestation and randomly assigned them (1:1) to either expressing breastmilk twice per day from 36 weeks' gestation (antenatal expressing) or standard care (usual midwifery and obstetric care, supplemented by support from a diabetes educator). Randomisation was done with a computerised random number generator in blocks of size two and four, and was stratified by site, parity, and diabetes type. Investigators were masked to block size but masking of caregivers was not possible. The primary outcome was the proportion of infants admitted to the NICU. We did the analyses by intention to treat; the data were obtained and analysed masked to group allocation. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12611000217909.Between June 6, 2011, and Oct 29, 2015, we recruited and randomly assigned 635 women: 319 to antenatal expressing and 316 to standard care. Three were not included in the primary analysis (one withdrawal from the standard care group, and one post-randomisation exclusion and one withdrawal from the antenatal expressing group). The proportion of infants admitted to the NICU did not differ between groups (46 [15%] of 317 assigned to antenatal expressing vs 44 [14%] of 315 assigned to standard care; adjusted relative risk 1·06, 95% CI 0·66 to 1·46). In the antenatal expressing group, the most common serious adverse event for infants was admission to the NICU for respiratory support (for three [1%] of 317. In the standard care group, the most common serious adverse event for infants was moderate to severe encephalopathy with or without seizures (for three [1%] of 315).There is no harm in advising women with diabetes in pregnancy at low risk of complications to express breastmilk from 36 weeks' gestation.Australian National Health and Medical Research Council.

In 2015 Nippita and colleagues developed a novel system to classify women undergoing induction of labour (IOL), which sought to overcome the problems of indication-based classification. We explored the utility and feasibility of this new system at Monash Health in Melbourne. We found overall induction rates of 24.7% compared with the New South Wales rates of 25.4% reported by Nippita et al. The classification system was easy to apply because it uses routinely and accurately collected data. There was no misinterpretation of the classification groups. The system provides a robust means for auditing IOLs and reviewing their appropriateness.

Background Stillbirth is a devastating pregnancy outcome that has a profound and lasting impact on women and families. Globally, there are over 2.6 million stillbirths annually and progress in reducing these deaths has been slow. Maternal perception of decreased fetal movements (DFM) is strongly associated with stillbirth. However, maternal awareness of DFM and clinical management of women reporting DFM is often suboptimal. The My Baby’s Movements trial aims to evaluate an intervention package for maternity services including a mobile phone application for women and clinician education (MBM intervention) in reducing late gestation stillbirth rates. Methods/design This is a stepped wedge cluster randomised controlled trial with sequential introduction of the MBM intervention to 8 groups of 3–5 hospitals at four-monthly intervals over 3 years. The target population is women with a singleton pregnancy, without lethal fetal abnormality, attending for antenatal care and clinicians providing maternity care at 26 maternity services in Australia and New Zealand. The primary outcome is stillbirth from 28 weeks’ gestation. Secondary outcomes address: a) neonatal morbidity and mortality; b) maternal psychosocial outcomes and health-seeking behaviour; c) health services utilisation; d) women’s and clinicians’ knowledge of fetal movements; and e) cost. 256,700 births (average of 3170 per hospital) will detect a 30% reduction in stillbirth rates from 3/1000 births to 2/1000 births, assuming a significance level of 5%. Analysis will utilise generalised linear mixed models. Discussion Maternal perception of DFM is a marker of an at-risk pregnancy and commonly precedes a stillbirth. MBM offers a simple, inexpensive resource to reduce the number of stillborn babies, and families suffering the distressing consequences of such a loss. This large pragmatic trial will provide evidence on benefits and potential harms of raising awareness of DFM using a mobile phone app. Trial registration ACTRN12614000291684. Registered 19 March 2014. Version Protocol Version 6.1, February 2018.

Aims: The worldwide prevalence of gestational diabetes mellitus (GDM) is increasing. Studies in rodent models indicate that hyperglycaemia during pregnancy alters kidney development, yet few studies have examined if this is so in humans. The objective of this study was to evaluate the association of treated GDM with foetal kidney size. Materials and Methods: Participants were recruited from an Australian tertiary hospital, and clinical data were collected from women without GDM and women diagnosed and treated for GDM and their offspring. Participants underwent an obstetric ultrasound at 32‐34 weeks gestation for foetal biometry and foetal kidney volume measurement. Results: Sixty‐four non‐GDM and 64 GDM women participated in the study. Thirty percent of GDM women were diagnosed with fasting hyperglycaemia, while 89% had an elevated 2‐hour glucose level. Maternal age, weight and body mass index were similar in women with and without GDM. Estimated foetal weight, foetal kidney dimensions, total foetal kidney volume and birth weight were similar in offspring of women with and without GDM. Conclusions: We conclude that a period of mild hyperglycaemia prior to diagnosis of GDM and treatment initiation, which coincides with a period of rapid nephron formation and kidney growth, does not alter kidney size at 32‐34 weeks gestation.

BACKGROUND Identifying mental health disorders in migrant and refugee women during pregnancy provides an opportunity for interventions that may benefit women and their families. Evidence suggests that perinatal mental health disorders impact mother-infant attachment at critical times, which can affect child development. Postnatal depression resulting in suicide is one of the leading causes of maternal mortality postpartum. Routine screening of perinatal mental health is recommended to improve the identification of depression and anxiety and to facilitate early management. However, screening is poorly implemented into routine practice. This study is the first to investigate routine screening for perinatal mental health in a maternity setting designed for refugee women. This study will determine whether symptoms of depression and anxiety are more likely to be detected by the screening program compared with routine care and will evaluate the screening program’s feasibility and acceptability to women and health care providers (HCPs). OBJECTIVE The objectives of this study are (1) to assess if refugee women are more likely to screen risk-positive for depression and anxiety than nonrefugee women, using the Edinburgh Postnatal Depression Scale (EPDS); (2) to assess if screening in pregnancy using the EPDS enables better detection of symptoms of depression and anxiety in refugee women than current routine care; (3) to determine if a screening program for perinatal mental health in a maternity setting designed for refugee women is acceptable to women; and (4) to evaluate the feasibility and acceptability of the perinatal mental health screening program from the perspective of HCPs (including the barriers and enablers to implementation). METHODS This study uses an internationally recommended screening measure, the EPDS, and a locally developed psychosocial questionnaire, both administered in early pregnancy and again in the third trimester. These measures have been translated into the most common languages used by the women attending the clinic and are administered via an electronic platform (iCOPE). This platform automatically calculates the EPDS score and generates reports for the HCP and woman. A total of 119 refugee women and 155 nonrefugee women have been recruited to evaluate the screening program’s ability to detect depression and anxiety symptoms and will be compared with 34 refugee women receiving routine care. A subsample of women will participate in a qualitative assessment of the screening program’s acceptability and feasibility. Health service staff have been recruited to evaluate the integration of screening into maternity care. RESULTS The recruitment is complete, and data collection and analysis are underway. CONCLUSIONS It is anticipated that screening will increase the identification and management of depression and anxiety symptoms in pregnancy. New information will be generated on how to implement such a program in feasible and acceptable ways that will improve health outcomes for refugee women. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/13271

Background Birth at home is a safe and appropriate choice for healthy women with a low risk pregnancy. However there is a small risk of emergencies requiring immediate, skilled management to optimise maternal and neonatal outcomes. We developed and implemented a simulation workshop designed to run in a home based setting to assist with emergency training for midwives and paramedical staff. The workshop was evaluated by assessing participants’ satisfaction and response to key learning issues. Methods Midwifery and emergency paramedical staff attending home births participated in a simulation workshop where they were required to manage birth emergencies in real time with limited availability of resources to suit the setting. They completed a pre-test and post-test evaluation form exploring the content and utility of the workshops. Content analysis was performed on qualitative data regarding the most important learning from the simulation activity. Results A total of 73 participants attended the workshop (midwifery = 46, and paramedical = 27). There were 110 comments, made by 49 participants. The most frequently identified key learning elements were related to communication (among midwives, paramedical and hospital staff and with the woman's partner), followed by recognising the role of other health care professionals, developing an understanding of the process and the importance of planning ahead. Conclusion Home birth simulation workshop was found to be a useful tool by staff that provide care to women who are having a planned home birth. Developing clear communication and teamwork were found to be the key learning principles guiding their practice.

Background Perinatal stress is associated with adverse maternal and infant outcomes. Mindfulness training may offer a safe and acceptable strategy to support perinatal mental health. Aim To critically appraise and synthesise the best available evidence regarding the effectiveness of mindfulness training during pregnancy to support perinatal mental health. Methods The search for relevant studies was conducted in six electronic databases and in the grey literature. Eligible studies were assessed for methodological quality according to standardised critical appraisal instruments. Data were extracted and recorded on a pre-designed form and then entered into Review Manager. Findings Nine studies were included in the data synthesis. It was not appropriate to combine the study results because of the variation in methodologies and the interventions tested. Statistically significant improvements were found in small studies of women undertaking mindfulness awareness training in one study for stress (mean difference (MD) −5.28, 95% confidence intervals (CI) −10.4 to −0.42, n = 22), two for depression (for example MD −5.48, 95% CI −8.96 to −2.0, n = 46) and four for anxiety (for example, MD −6.50, 95% CI −10.95 to −2.05, n = 32). However the findings of this review are limited by significant methodological issues within the current research studies. Conclusion There is insufficient evidence from high quality research on which to base recommendations about the effectiveness of mindfulness to promote perinatal mental health. The limited positive findings support the design and conduct of adequately powered, longitudinal randomised controlled trials, with active controls.

Introduction Inequalities in maternal and newborn health persist in many high-income countries, including for women of refugee background. The Bridging the Gap partnership programme in Victoria, Australia, was designed to find new ways to improve the responsiveness of universal maternity and early child health services for women and families of refugee background with the codesign and implementation of iterative quality improvement and demonstration initiatives. One goal of this ‘whole-of-system’ approach was to improve access to antenatal care. The objective of this paper is to report refugee women’s access to hospital-based antenatal care over the period of health system reforms. Methods and findings The study was designed using an interrupted time series analysis using routinely collected data from two hospital networks (four maternity hospitals) at 6-month intervals during reform activity (January 2014 to December 2016). The sample included women of refugee background and a comparison group of Australian-born women giving birth over the 3 years. We describe the proportions of women of refugee background (1) attending seven or more antenatal visits and (2) attending their first hospital visit at less than 16 weeks’ gestation compared over time and to Australian-born women using logistic regression analyses. In total, 10% of births at participating hospitals were to women of refugee background. Refugee women were born in over 35 countries, and at one participating hospital, 40% required an interpreter. Compared with Australian-born women, women of refugee background were of similar age at the time of birth and were more likely to be having their second or subsequent baby and have four or more children. At baseline, 60% of refugee-background women and Australian-born women attended seven or more antenatal visits. Similar trends of improvement over the 6-month time intervals were observed for both populations, increasing to 80% of women at one hospital network having seven or more visits at the final data collection period and 73% at the other network. In contrast, there was a steady decrease in the proportion of women having their first hospital visit at less than 16 weeks’ gestation, which was most marked for women of refugee background. Using an interrupted time series of observational data over the period of improvement is limited compared with using a randomisation design, which was not feasible in this setting. Conclusions Accurate ascertainment of ‘harder-to-reach’ populations and ongoing monitoring of quality improvement initiatives are essential to understand the impact of system reforms. Our findings suggest that improvement in total antenatal visits may have been at the expense of recommended access to public hospital antenatal care within 16 weeks of gestation., Jane Yelland and colleagues report refugee women's access to antenatal services in Australia during a period of health systems reform., Author summary Why was the study done? Women of refugee background have rates of stillbirth and perinatal mortality two to three times higher than Australian-born women. Antenatal care is a key preventive strategy for the optimal health of pregnant women and newborn babies and is critical to addressing modifiable factors for poor health outcomes. Refugee women experience barriers in accessing and engaging in antenatal care, and healthcare providers report challenges in responding to the social context and needs of refugee families. What did the researchers do and find? We codesigned and implemented multiple quality improvement and demonstration initiatives in universal health services, including four maternity hospitals. We used an interrupted time series design to assess the timing and number of antenatal clinical visits for refugee women compared with Australian-born women over 3 years of reform. Applying a method devised by the partnership, we identified from routinely collected data that 10% of all women giving birth at the participating hospitals were of refugee background. There was an increase over time in the proportion of refugee and Australian-born women attending the standard number of visits, with women of refugee background commencing hospital antenatal care well past the recommended gestation. What do these findings mean? For women of refugee background, delayed access to hospital-based care increases the likelihood of missing out on critical elements of pregnancy care vital to optimising maternal and child outcomes. Accurate ascertainment of this ‘harder-to-reach’ population is essential to evaluating the impact of quality improvement initiatives on refugee families’ access to healthcare. An interrupted time series design with a comparison group is suited to measuring change in number and timing of antenatal visits, although data quality, contextual influences, and qualitative insights into system change are important for interpreting outcomes. Ongoing monitoring of quality improvement initiatives on populations vulnerable to poor health outcomes is essential to understand the impact of system reforms and efforts to reduce inequalities.

Objective To compare maternal health, prenatal care, and pregnancy outcomes among women of refugee background (born in Asian humanitarian source countries [HSCs]) and non-refugee background (born in Asian non-HSCs) at Monash Health (Melbourne, VIC, Australia). Methods In a retrospective study, data were obtained for women born in HSCs and non-HSCs from the same region who received government-funded health care for singleton pregnancies between 2002 and 2011. Multivariable regression analyses assessed associations between maternal HSC origin and pregnancy outcomes. Results Data were included for 1930 women from South Asian HSCs and 7412 from non-HSCs, 107 from Southeast Asian HSCs and 5574 from non-HSCs, 287 from West Asian HSCs and 990 from non-HSCs. Overweight, anemia, and teenage pregnancy were generally more common in the HSC groups. Birth in an HSC was independently associated with poor/no pregnancy care attendance (OR 4.2; 95% CI 2.5–7.3), late booking visit (OR 1.3; 95% CI 1.1–1.5), and post-term birth (OR 3.0; 95% CI 2.0–4.5) among women from South Asia. For Southeast Asia, HSC birth was independently associated with labor induction (OR 2.0; 95% CI 1.1–3.5). No independent associations were recorded for West Asia. Conclusion Women born in Afghanistan, Bhutan, Iraq, and Myanmar had poorer general maternal health. Those from South Asian HSCs had increased risks of lower engagement in prenatal care, and post-term birth.

ObjectiveTo examine associations between maternal Asian ethnicity (South Asian and South East/East Asian) and anal sphincter injury.DesignRetrospective cross-sectional study, comparing outcomes for Asian women with those of Australian and New Zealand women.SettingA large metropolitan maternity service in Victoria, Australia.PopulationAustralian/New Zealand, South Asian and South East/East Asian women who had a singleton vaginal birth from 2006 to 2012.MethodsThe relation between maternal ethnicity and anal sphincter injury was assessed by logistic regression, adjusting for potential confounders.Main outcome measuresAnal sphincter injury was defined as a third or fourth degree tear (with or without episiotomy).ResultsAmong 32653 vaginal births there was a significant difference in the rate of anal sphincter injury by maternal region of birth (p

Objective to identify the perceptions of midwives and doctors at Monash Women׳s regarding their educational preparation and practices used for perineal management during the second stage of labour. Design anonymous cross-sectional semi-structured questionnaire (‘The survey'). Setting the three maternity hospitals that form Monash Women׳s Maternity Services, Monash Health, Victoria, Australia. Participants midwives and doctors attending births at one or more of the three Monash Women׳s maternity hospitals. Methods a semi-structured questionnaire was developed, drawing on key concepts from experts and peer-reviewed literature. Findings surveys were returned by 17 doctors and 69 midwives (37% response rate, from the 230 surveys sent). Midwives and doctors described a number of techniques they would use to reduce the risk of perineal trauma, for example, hands on the fetal head/perineum (11.8% of doctors, 61% of midwives), the use of warm compresses (45% of midwives) and maternal education and guidance with pushing (49.3% of midwives). When presented with a series of specific obstetric situations, respondents indicated that they would variably practice hands on the perineum during second stage labour, hands off and episiotomy. The majority of respondents indicated that they agreed or strongly agreed that an episiotomy should sometimes be performed (midwives 97%, doctors 100%). All the doctors had training in diagnosing severe perineal trauma involving anal sphincter injury (ASI), with 77% noting that they felt very confident with this. By contrast, 71% of the midwives reported that they had received training in diagnosing ASI and only 16% of these reported that they were very confident in this diagnosis. All doctors were trained in perineal repair, compared with 65% of midwives. Doctors were more likely to indicate that they were very confident in perineal repair (88%) than the midwives (44%). Most respondents were not familiar with the rates of perineal trauma either within their workplace or across Australia. Key conclusions Midwives and doctors indicated that they would use the hands on or hands off approach or episiotomy depending on the specific clinical scenario and described a range of techniques that they would use in their overall approach to minimising perineal trauma during birth. Midwives were more likely than doctors to indicate their lack of training and/or confidence in conducting perineal repair and diagnosing ASI. Implications for practice many midwives indicated that they had not received training in diagnosing ASI, perineal repair and midwives׳ and doctor׳s knowledge of the prevalence of perineal outcomes was poor. Given the importance of these skills to women cared for by midwives and doctors, the findings may be used to inform the development of quality improvement activities, including training programs and opportunities for gaining experience and expertise with perineal management. The use of episiotomy and hands on/hands off the perineum in the survey scenarios provides reassurance that doctors and midwives take a number of factors into account in their clinical practice, rather than a preference for one or more interventions over others.

Summary Aim To evaluate the addition of fasting glucose and lipids to a simple, validated risk prediction tool for gestational diabetes (GDM) applied in early pregnancy. Methods Women at risk of developing GDM on a validated risk prediction tool were recruited in early pregnancy into a large randomised controlled trial. Outcome measures included fasting biochemical markers (glucose, lipids) at 12–15 weeks gestation and GDM diagnosis (28 weeks gestation). Multivariable logistic regression was used to identify additional predictive biochemical variables for GDM, with corresponding receiver operator characteristic (ROC) curves generated. Unadjusted and adjusted models were derived for both the Australasian Diabetes in Pregnancy (ADIPS) and the International Association for Diabetes in Pregnancy Study Group (IADPSG) GDM diagnostic criteria. Results 51 (23%) Women were diagnosed with GDM based on ADIPS criteria, with 60 (30%) diagnosed based on IADPSG criteria. In all four regression models, fasting glucose was the strongest predictor for GDM development with an odds ratio range of 4.7–6.3 (ADIPS) and 8.8–10 (IADPSG). ROC curves revealed an area under the curve of 0.79 (95% CI: 0.72–0.86) for ADIPS criteria and 0.83 (95% CI: 0.77–0.90) for IADPSG criteria for adjusted models. Conclusions In a two-step approach, when applied with a validated risk prediction tool, fasting glucose in early pregnancy was predictive of GDM and incrementally improved risk identification, presenting potential for an early pregnancy, GDM risk screening strategy for streamlining of pregnancy care and opportunity for preventive intervention.

Background Obesity during pregnancy is a serious health problem for women and their children. Despite the high prevalence of high body mass index (BMI) among women of reproductive age in high-income countries, there is insufficient evidence to inform practice and policy about weight management for women with high BMI who are pregnant. The aim of this project was to describe women’s and midwives’ experiences and perspectives of care for weight management during pregnancy in Melbourne, Australia. Methods A qualitative study. Semi-structured interviews were conducted with pregnant women and midwives. Transcripts were analysed thematically. Results A total of 17 women and 2 midwives were interviewed. Five themes were identified: 1. Reluctance to and difficulties discussing weight and its implications; 2. Barriers to providing appropriate pregnancy care for women with high BMI; 3. Inconsistent weighing practices; 4. Beliefs about the causes of obesity; and 5. Opportunities to assist women to manage their weight. Although most women were satisfied with the pregnancy care they had received, both women and midwives expressed concerns about effective weight management during pregnancy. These included constraints on discussing weight, difficulties accessing appropriate resources and additional support from other health care providers, and inconsistent weighing practices. Conclusions The findings suggest that women with high BMI would benefit from additional information and support about weight management prior to conception, during pregnancy, and postnatally.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: 1. To assess the effects of interventions designed to improve care co‐ordination between separately funded services during pregnancy and early childhood (up to 5 years). 2. To provide a brief economic commentary that will summarise the availability and principal findings of eligible economic evaluations.

Background Identifying mental health disorders in migrant and refugee women during pregnancy provides an opportunity for interventions that may benefit women and their families. Evidence suggests that perinatal mental health disorders impact mother-infant attachment at critical times, which can affect child development. Postnatal depression resulting in suicide is one of the leading causes of maternal mortality postpartum. Routine screening of perinatal mental health is recommended to improve the identification of depression and anxiety and to facilitate early management. However, screening is poorly implemented into routine practice. This study is the first to investigate routine screening for perinatal mental health in a maternity setting designed for refugee women. This study will determine whether symptoms of depression and anxiety are more likely to be detected by the screening program compared with routine care and will evaluate the screening program’s feasibility and acceptability to women and health care providers (HCPs). Objective The objectives of this study are (1) to assess if refugee women are more likely to screen risk-positive for depression and anxiety than nonrefugee women, using the Edinburgh Postnatal Depression Scale (EPDS); (2) to assess if screening in pregnancy using the EPDS enables better detection of symptoms of depression and anxiety in refugee women than current routine care; (3) to determine if a screening program for perinatal mental health in a maternity setting designed for refugee women is acceptable to women; and (4) to evaluate the feasibility and acceptability of the perinatal mental health screening program from the perspective of HCPs (including the barriers and enablers to implementation). Methods This study uses an internationally recommended screening measure, the EPDS, and a locally developed psychosocial questionnaire, both administered in early pregnancy and again in the third trimester. These measures have been translated into the most common languages used by the women attending the clinic and are administered via an electronic platform (iCOPE). This platform automatically calculates the EPDS score and generates reports for the HCP and woman. A total of 119 refugee women and 155 nonrefugee women have been recruited to evaluate the screening program’s ability to detect depression and anxiety symptoms and will be compared with 34 refugee women receiving routine care. A subsample of women will participate in a qualitative assessment of the screening program’s acceptability and feasibility. Health service staff have been recruited to evaluate the integration of screening into maternity care. Results The recruitment is complete, and data collection and analysis are underway. Conclusions It is anticipated that screening will increase the identification and management of depression and anxiety symptoms in pregnancy. New information will be generated on how to implement such a program in feasible and acceptable ways that will improve health outcomes for refugee women. International Registered Report Identifier (IRRID) DERR1-10.2196/13271

BackgroundThe effects of place of birth on birth outcomes have been examined in several studies both locally and internationally. However, none has examined the impact on caesarean section rates of different level maternity hospitals operating within the one health service. This study aimed to examine the impact of place of (Hospital level 6; 4-5 or 4) on birth outcomes in a large metropolitan health service in Victoria.MethodsA cross-sectional study utilising data on births to low-risk first-time mothers during 2010-2011. Data were obtained from the Birthing Outcome System (BOS) database of Monash Health. Unadjusted and adjusted analyses were undertaken using logistic regression to examine the association between place of birth and caesarean section.ResultsIn this group of low-risk nulliparae, there was evidence of a significant association between place of birth and caesarean section. The lower the acuity of the hospital, the higher the odds for the caesarean section. Compared with the level 6 hospital, the AdjOR for caesarean section at the level 4 hospital was 1.81 (95% CI: 1.37-2.41) and at the level 4-5 hospital, 1.30 (95% CI: 1.0-1.7).ConclusionsLow-risk nulliparae in spontaneous labour giving birth at the level 4 hospital in this health service are at significantly increased risk of caesarean section. This may have implications for the organisation and resource management of other level 4 public maternity units. Care in a tertiary (level 6) service may not necessarily equate to the higher rates of intervention reported by others.