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The perinatal period is a time when provision of responsive care offers a life course opportunity for positive change to improve health outcomes for mothers, infants and families. Australian perinatal systems carry the legacy of settler-colonialism, manifesting in racist events and interactions that First Nations parents encounter daily. The dominance of a western risk lens, and conscious and unconscious bias in the child protection workforce, sustains disproportionately high numbers of First Nations infants being removed from their parents' care. Cascading medical interventions compound existing stressors and magnify health inequities for First Nations women. Critical discourse was informed by Indigenous ways of knowing, being and doing via targeted dialogue with a group of First Nations and non-Indigenous experts in Australian perinatal care who are co-authors on this paper. Dynamic discussion evolved from a series of yarning circles, supplemented by written exchanges and individual yarns as themes were consolidated. First Nations maternity services prioritise self-determination, partnership, strengths and communication and have demonstrated positive outcomes with, and high satisfaction from First Nations women. Mainstream perinatal settings could be significantly enhanced by embracing similar principles and models of care. The Australian Anti-racism in Perinatal Practice (AAPP) Alliance calls for urgent transformations to Australian perinatal models of care whereby non-Indigenous health policy makers, managers and clinicians take a proactive role in identifying and redressing ethnocentrism, judgemental and culturally blind practices, reframing the risk narrative, embedding strength-based approaches and intentionally prioritising engagement and connectedness within service delivery. [Abstract copyright: Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.]

This study aimed to explore women's and clinician's experiences and acceptability of telehealth use within a specialized multidisciplinary menopause service during the COVID-19 pandemic.In-depth qualitative semi-structured interviews were analyzed via thematic inductive approaches. Telehealth acceptability was guided by the Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies (NASSS) framework.A heterogeneous group of 18 women who had attended the menopause service and six clinicians (gynecologists and endocrinologists) were interviewed. The majority of women and clinicians perceived telehealth as an acceptable way to deliver menopause care. Benefits of telehealth delivery were identified; themes centered around convenience, greater access to care and improved safety. Telehealth challenges included perceived impacts on personalized quality of care, patient-related logistical issues and system/organizational-related issues. A hybrid flexible delivery model combining telehealth and face-to-face care was recommended, following the easing of COVID-19 restrictions. Improvements to support embedding and adaptation of telehealth into routine care were described.In this study, telehealth was viewed as acceptable, supporting the ongoing delivery of a hybrid service model of telehealth and face-to-face menopause care. The findings provide valuable information to improve the menopause service to meet the needs of women during the ongoing current pandemic and beyond.

Polycystic ovary syndrome (PCOS) affects 5-18% of women, and is a reproductive, metabolic, and psychological condition with impacts across the lifespan. The cause is complex, and includes genetic and epigenetic susceptibility, hypothalamic and ovarian dysfunction, excess androgen exposure, insulin resistance, and adiposity-related mechanisms. Diagnosis is recommended based on the 2003 Rotterdam criteria and confirmed with two of three criteria: hyperandrogenism (clinical or biochemical), irregular cycles, and polycystic ovary morphology. In adolescents, both the criteria of hyperandrogenism and irregular cycles are needed, and ovarian morphology is not included due to poor specificity. The diagnostic criteria generates four phenotypes, and clinical features are heterogeneous, with manifestations typically arising in childhood and then evolving across adolescent and adult life. Treatment involves a combination of lifestyle alterations and medical management. Lifestyle optimisation includes a healthy balanced diet and regular exercise to prevent excess weight gain, limit PCOS complications and target weight reduction when needed. Medical management options include metformin to improve insulin resistance and metabolic features, combined oral contraceptive pill for menstrual cycle regulation and hyperandrogenism, and if needed, anti-androgens for refractory hyperandrogenism. In this Review, we provide an update on the pathophysiology, diagnosis, and clinical features of PCOS, and discuss the needs and priorities of those with PCOS, including lifestyle, and medical and infertility treatment. Further we discuss the status of international evidence-based guidelines (EBG) and translation, to support patient self management, healthcare provision, and to set research priorities.

Objective: To investigate the management of subfertility and infertility among Aboriginal and Torres Strait Islander females attending Australian general practice. Methods: Cross-sectional study of 1,258,581 women (18-49 years) attending general practice between January 2011 and June 2019, utilising data from NPS MedicineWise MedicineInsight, a national general practice database in Australia. Results: The prevalence of subfertility/infertility encounters was lower for Aboriginal and Torres Strait Islander females (12.4 per 1000) than for non-Indigenous females (16.6 per 1000). Aboriginal and Torres Strait Islander females with a subfertility/infertility encounter were younger and more likely to live outside Major cities and in areas of socioeconomic disadvantage than non-Indigenous females. Rates of prescribed infertility medications were not different between groups, however Aboriginal and Torres Strait Islander females were more likely to receive a pelvic ultrasound (24.3% vs. 19.9%); tests for LH (31.9% vs. 25.7%), testosterone (14.9% vs. 10.0%) and HbA1c (6.3% vs. 3.4%); but less likely to receive an AMH test (2.8% vs. 7.0%). Conclusions: Lower encounter rates for infertility/subfertility among Aboriginal and Torres Strait Islander people may indicate access issues, preferred use of Aboriginal community-controlled health centres or younger average age at first birth and thus less age-related infertility. Implications for public health: Future efforts should focus on maximising the inclusiveness of infertility surveillance. There is also a needfor further research into the experiences of and preferences for infertility care and associated barriers among Aboriginal and Torres Strait Islander people.

Unplanned pregnancy in adolescents contributes to the burden of disease, mortality, and health and educational disparities experienced by young people during this vulnerable period between childhood and adulthood. Reproductive life planning (RLP) is an approach that has been endorsed and adopted internationally, which prompts individuals and couples to set personal goals regarding if and when to have children based on their own personal priorities. This review discusses RLP tools, their acceptability, effectiveness, and issues in implementation across different contexts, with a specific focus on how RLP has been applied for adolescents. While a range of RLP tools are available and considered acceptable in adult populations, there is minimal evidence of their potential benefits for adolescent populations. Online platforms and information technology are likely to promote reach and implementation of RLP interventions in adolescents. Consideration of the socioecological contexts where adolescent pregnancies are more common should be integral to much needed future work that explores RLP interventions in adolescents.

The aim of this study was to investigate symptomatology and diagnoses of PTSD and subthreshold PTSD and the screening properties of the Harvard Trauma Questionnaire (HTQ) within a sample of Dari-speaking women of refugee background receiving antenatal care. This cross-sectional study administered the HTQ to 52 Dari-speaking women at a public pregnancy clinic. The trauma module from the Structured Clinical Interview (SCID-5) was administered. Interview material was presented to an expert panel, blinded to the HTQ screening results, in order to achieve consensus diagnoses of PTSD using Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) criteria. Three women (5.8%) met DSM-5 criteria for PTSD. Eleven women (21.15%) met criteria for subthreshold PTSD, defined as meeting two or three of the DSM-5 criteria domains. A comparison of HTQ cut-off scores was conducted and a score of ≥ 2.25 on the HTQ demonstrated excellent sensitivity 1.00 (95% CI 0.29-1.00) and specificity 0.76 (95% CI 0.61-0.87) in detecting PTSD; however, a wide confidence interval for sensitivity was found. A cut-off score of ≥ 2 provided the best balance of sensitivity 1.00 (95% CI 0.72-1.00) and specificity 0.80 (95% CI 0.65-0.91) when assessing for subthreshold PTSD. Screening for perinatal PTSD for women of refugee background is recommended, in order to identify those at risk of DSM diagnosis and also those women experiencing distressing PTSD symptomatology.

Background The COVID-19 pandemic has significantly impacted the delivery of diabetes in pregnancy care and general maternity care. This study aimed to explore the experiences and acceptability of telehealth use in diabetes in pregnancy care during the COVID-19 pandemic, from the perspectives of pregnant women and their clinicians. The secondary aim was to assess differences in telehealth experiences for diabetes and general maternity care. Methods In-depth qualitative semi-structured interviews were undertaken and analysed via thematic inductive approaches. The Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies Framework (NASSS) was applied. Results 18 interviews were conducted with culturally and linguistically diverse pregnant women and 4 clinicians (endocrinologists and dietitians). All interviewees were satisfied with telehealth as a positive alternative to face-to-face consultations for diabetes care during the COVID-19 pandemic. Numerous benefits of delivering diabetes care via telehealth were discussed and themes centred around greater access to care, economic benefits and improved safety. Most barriers concerned the adopters (clinicians), yet, feasible and realistic suggestions to overcome barriers were voiced. The scope for technology adaptation and ongoing embedment into routine diabetes care was described. Overall, a hybrid flexible delivery model, predominantly consisting of telephone consultations, with some face-to-face consultations for initial diabetes appointments was recommended for future care. The use of telehealth in replacement of face-to-face appointments for general maternity care was perceived as reducing care quality. Conclusion In this study, telehealth was viewed as acceptable to women and clinicians for diabetes in pregnancy care, supporting the ongoing delivery of a hybrid service model of telehealth and face-to-face care. These findings provide valuable information to improve diabetes in pregnancy services to meet the needs of women during the COVID-19 pandemic and beyond.

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.

The preconception period provides a significant opportunity to engage women in healthy behaviour change for improved maternal and child health outcomes. However, there is limited research exploring women's pregnancy planning in Australia.This study investigated associations between pregnancy planning, socio-demographics and preconception health behaviours in Australian women.A retrospective cross-sectional survey of pregnant women ≥18-years-of-age recruited through a Victorian public maternity service and a national private health insurer.Overall 317 women (30±4.7 years) participated (public: n=225, private: n=92). Planned pregnancies were reported by 74% of women and were independently associated with marital status (AOR=5.71 95% CI 1.92-17.00, p=0.002); having ≤2 children (AOR=3.75 95% CI 1.28-11.05, p=0.016); and having private health insurance (AOR=2.51 95% CI 1.08-5.81, p=0.03). Overall, women reported preconception: any folic-acid supplementation (59%), up-to-date cervical screening (68%), weight management attempts (75%), accessing information from health professionals (57%) and immunisation reviews (47%). Pregnancy planners were more likely to use folic-acid (AOR=17.13 95% CI 7.67-38.26, p0.001), review immunisations (AOR=2.09 95% CI 1.07-4.10, p=0.03) and access information (AOR=3.24 95% CI 1.75-6.00, p0.001) compared to non-planners. Women25-years-of-age were less likely to access information (AOR=0.38 95% CI 0.16-0.89, p=0.03) and take folic-acid (AOR=0.23 95% CI 0.09-0.59, p=0.002) and were more likely to smoke 3-months preconception (AOR=6.68 95% CI 1.24-36.12, p=0.03).Women with planned and unplanned pregnancies reported variable preconception health behaviour uptake and limited healthcare engagement. Opportunities exist to improve awareness and healthcare engagement for optimising preconception health and pregnancy planning benefits including collaborative health promotion. Population-based and targeted approaches reaching pregnancy planners and non-planners are required.

ObjectiveTo examine the prevalence of COVID-19 vaccination, and factors associated with vaccination intention and hesitancy in pregnant and postnatal women in Australia.Design and settingA national online survey was conducted over 6 months between 31 August 2021 and 1 March 2022 and responses to vaccination status were categorised as: ‘vaccinated’, ‘vaccine intended’ and ‘vaccine hesitant’. The data were weighted to reflect the proportion of women of reproductive age. Potential confounding variables were examined using multinomial logistic regression analyses, and all comparisons were made against vaccinated pregnant and postnatal women.Participants2140 women responded to the survey (838 pregnant; 1302 recently post partum).ResultsAmongst pregnant women, 586 (69.9%) were vaccinated, 166 (19.8%) indicated intention and 86 (10.3%) were hesitant. In postnatal women, this was 1060 (81.4%), 143 (11.0%) and 99 (7.6%), respectively. Only 52 (6.2%) of pregnant women stated never wanting a COVID-19 vaccine. Vaccine hesitancy increased over time, and for pregnant women was associated with: living in a state other than New South Wales (NSW) (Adjusted Relative Risk (ARR) 2.77, 95%CI: 1.68-4.56 for vaccine intention and ARR=3.31, 95%CI: 1.52-7.20 for vaccine hesitancy), younger age ConclusionsAround 1 in 10 pregnant women and just over 1 in 13 postnatal women reported vaccine hesitancy in this Australian survey, and hesitancy was higher in the latter 3-month period. Tailored messages to younger mothers and those from lower-middle socioeconomic groups, alongside advice from midwives and obstetricians, could help to reduce hesitancy among pregnant and postnatal women. Financial incentives may help to facilitate COVID-19 vaccine uptake. A real-time surveillance system and additional pregnancy fields added to the Australian immunisation register would support the safety monitoring of multiple vaccines in pregnancy and may build confidence.

BACKGROUND Improving preconception health can benefit all women, their children and families, regardless of their individual pregnancy intentions. OBJECTIVE Explore how women engage with digital health resources and online platforms to inform the design and development of a digital health resource to support women to make positive behaviour change for their preconception health. METHODS This co-design research followed the Double Diamond process. Phase one, contextualisation and explorative processes to develop a design brief, was undertaken via a series of in-depth interviews with female participants (n = 12) aged 18-45 years over three months. Community advisors (n = 8) provided feedback throughout the process. Qualitative analyses of transcripts from interviews was undertaken by two researchers before a deductive process identified themes mapped to the COM-B framework. RESULTS Nine themes and eight sub-themes were identified. Participants were already engaging with a range of digital health resources and had high expectations of these. Digital health resources needed to be easy to access, make women’s busy lives easier, be evidence-based, and be reputable. Social connectedness was also highly important to our participants, with information and advice from peers with similar experiences being preferred over yet more online health information. CONCLUSIONS Co-designed digital health resources should be evidence-based, reputable and easy to access. Social connections were considered highly important to women and designers of digital health resources should consider how they can increase opportunities for women to connect and learn from each other to promote health behaviours.

School-based sexual and reproductive health (SRH) education is often reported as being inadequate and/or inconsistent. The aims of this systematic review were to synthesise teachers’ perspectives o...

Issue addressed Sub-optimal lifestyle choices made long before pregnancy have the potential to impact negatively maternal health and pregnancy outcomes. However, many women are unaware of this and do not seek preconception health advice. Methods Using a descriptive qualitative approach, non-pregnant women (n=31) aged 18 to 45 years were purposively recruited to participate in a focus group (n=7) that explored how preconception health is prioritised and how to increase women's awareness and uptake of healthy lifestyle behaviours in the preconception period. Focus group transcripts were coded by two researchers and an inductive process was used to categorise codes into themes. Results Two themes and five sub-themes relating to the aims of this study were identified. Participants believed preconception health to be important for all women, while admitting that was not a high priority if not planning a pregnancy. Participants suggested a range of interventions that spanned the social-ecological model of health to engage preconception women in preventive actions and promote preconception health. These interventions included having access to reputable and easily accessible online sources of preconception health information, education and at secondary schools and public health campaigns. Conclusions Future initiatives to engage preconception women should span the social-ecological model of health and consider women's personal preferences for accessible and tailored preconception health information and support at individual, interpersonal, community and organisational levels, as well as in the broader environment. SO WHAT?: This research provides guidance to those in health promotion when planning future initiatives to promote and protect women's preconception health.

Early menopause/premature ovarian insufficiency is associated with negative health impacts, unmet information needs, delayed diagnosis, and variation in management. Co-designed digital resources for women with early menopause/premature ovarian insufficiency and health practitioners were developed to address information needs and support management. A five-phase mixed methods multidisciplinary research, co-design and translation process comprised: (1) survey/interviews with women and health practitioners to explore early menopause/premature ovarian insufficiency needs, experiences, and management; (2) appraisal of clinical guidelines to develop management algorithms; (3) digital resource development (https://healthtalkaustralia.org/early-menopause-experiences-and-perspectives-of-women-and-health-professionals/; (4) evaluation; and (5) dissemination/implementation. The digital resources included audio/video clips of women with early menopause/premature ovarian insufficiency and health practitioners providing early menopause/premature ovarian insufficiency care, a question prompt list, health practitioner algorithms, information links, and a list of services for women, achieving high satisfaction ratings from women and health practitioners. Engaging our stakeholder partners, multimodal dissemination has included community and conference presentations, social media, lay and professional publications, and webinars. This project provides a model for successful interdisciplinary co-design research translation to improve women's health.

Issue addressed Healthy behaviours prior to conception can improve pregnancy outcomes and intergenerational health. Adolescence is an important period to promote preconception health, but education resources need to be age and culturally appropriate. Few studies have addressed preconception awareness and knowledge among Aboriginal and Torres Strait Islander youth, and few culturally appropriate resources exist. Methods A mixed methods, co-design process engaging Aboriginal and Torres Strait Islander youth and an Indigenous Reference Group (IRG). Additionally, a survey was carried out to identify preconception health awareness and interest among a broader youth audience. Results Several main themes emerged from consultation meetings with youth reflecting an awareness of preconception health, but limited understanding. Youth revealed an interest in fertility, and a need for more information on lifestyle factors associated with infertility. Preconception information related to the opposite sex was seen as important as well as information incorporating current local knowledge and world views. Among the survey respondents, 46% (11/24) had a pre-existing understanding of preconception health. Optimising lifestyle behaviours prior to pregnancy was perceived as important for women (21/24; 88%), but less so for men (16/24; 67%), highlighting a gap in knowledge regarding the importance of preconception health for men. Conclusion The co-designed resource "Getting healthy before pregnancy" is available in print and electronically, with illustrations and synchronised audio overlay in Aboriginal English or East-side Kriol. The resource includes information on preconception health and behavioural risk factors. So what We present a co-designed preconception health resource for evaluation with Aboriginal and Torres Strait Islander youth.

Problem National guidelines recommending mental health screening in pregnancy have not been implemented well in routine maternity care. Women of refugee background are likely to have experienced traumatic events and resettlement stressors, yet are not often identified with mental health issues in the perinatal period. Background Globally, perinatal mental health conditions affect up to 20% of women. Many difficulties in accessing mental health care in pregnancy exist for women of refugee background including stigma, and cultural and language barriers. Technology can provide an efficient and effective method to overcome some of these barriers. Aim To determine if a digital perinatal mental health screening program is feasible and acceptable for women of refugee background. Methods This qualitative evaluation study used focus group and semi-structured telephone interviews with refugee and migrant women from four communities. Interpreters were used with women who spoke little or no English. Data were analysed using both an inductive and deductive approach to thematic analysis. Findings Under the three key themes: ‘Women’s experiences of perinatal mental health screening in pregnancy’; ‘Barriers and enablers to accessing ongoing mental health care’ and ‘Improvements to the program: the development of audio versions’, women found the program feasible and acceptable. Discussion Screening using a mobile device offered women more privacy and opened up discussions with midwives on emotional health. Improvements in service coordination and access to further mental health management for women is required. Conclusion Perinatal mental health screening is an acceptable and feasible option for women of refugee background. Integrated models of care, case management, and patient navigators are options for improvements in uptake of referral and treatment services.

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.

Background: Vulvar cancer is rare and, as a result, is understudied. Treatment is predominantly surgery, irrespective of the type of vulvar cancer, and is associated with physical, emotional and sexual complications. A cluster of human papillomavirus (HPV)-dependent vulvar cancer patients was identified in Arnhem Land Northern Territory (NT), Australia, in which young Indigenous women were diagnosed at 70 times the national incidence rate. Aims: To assess whether women from the Arnhem Land cluster differ from women with vulvar squamous cell carcinoma (VSCC) and vulvar intraepithelial neoplasia (VIN) resident elsewhere in the NT in recurrence after treatment, disease progression and mortality. Materials and methods: A retrospective cohort study of NT-resident women diagnosed with VIN or invasive vulvar cancer (VSCC) between 1 January 1993 and 30 June 2015 was undertaken. Time to recurrence was assessed using cumulative incidence plots and Fine and Gray competing risk regression models. Mean cumulative count was used to estimate the burden of recurrent events. Results: Indigenous women from Arnhem Land experienced more recurrences after treatment than non-Indigenous women, the cancers recurred faster, and Indigenous women have worse survival at five years. Conclusions: In characterising the epidemiological features of this cluster, we have identified a particularly aggressive form of vulvar cancer. This provides a unique opportunity for elucidating the aetiopathological pathways driving vulvar cancer development that may ultimately lead to preventive and therapeutic targets for this neglected malignancy. Further, these findings have important implications for clinical practice and HPV vaccination policy in the affected population.

Objectives: This community-based participatory research focused on physical and social barriers to healthcare for refugee women in Melbourne, Australia.Design: Women from non-English speaking backg...

Background Lifestyle interventions (diet, physical activity and/or behavioural) to optimise gestational weight gain can prevent adverse maternal outcomes such as gestational diabetes, pre-eclampsia and caesarean section. Objective We aimed to model the cost effectiveness of lifestyle interventions during pregnancy on reducing adverse maternal outcomes. Methods Decision tree modelling was used to determine the cost effectiveness of lifestyle interventions compared with usual care on preventing cases of gestational diabetes and hypertensive disease in pregnancy. Participants were pregnant women receiving routine antenatal care in secondary and tertiary care hospitals. The main outcome measures were cases of gestational diabetes and/or hypertensive disease in pregnancy prevented, costs, and incremental cost-effectiveness ratios. Analysis was conducted from the perspective of the Australian healthcare system, with a time horizon of early pregnancy to discharge after birth. Results Women in the intervention group were 2.25% less likely to have gestational diabetes and/or hypertensive disease in pregnancy (9.53%) compared with the control group (11.78%). Intervention costs were Australian dollars (AUD) 228 per person. Costs were AUD33 per person higher in the intervention group (AUD8281) than the control group (AUD8248). The incremental cost-effectiveness ratio was AUD1470 per case prevented. Sensitivity analysis showed that base-case results were robust. In the probabilistic sensitivity analysis, 44.8% of data points fell within the north-east quadrant, and 52.2% in the south-east quadrant (cost saving), with a 95% confidence interval ranging from AUD − 50,018 to 32,779 per case prevented. Conclusions While there is no formally accepted cost-effectiveness threshold for willingness-to-pay to prevent an adverse maternal event, the cost per person receiving a lifestyle intervention compared with controls was close to neutral, and therefore likely to be cost effective. Exploration of the cost effectiveness of different lifestyle delivery modes across various models of antenatal care is now required. Future cost-effectiveness studies should investigate longer time horizons, quality-adjusted life-years and productivity loss. Trial Registration Not applicable. Electronic supplementary material The online version of this article (10.1007/s41669-020-00197-9) contains supplementary material, which is available to authorized users.

Refereed/Peer-reviewed Background: Benefits of breastfeeding on infant growth in children born to mothers with gestational diabetes mellitus (GDM) are uncertain. Objectives: To describe growth trajectories between birth and 14 months according to breastfeeding and maternal hyperglycaemia in pregnancy, and assess associations between breastfeeding and 14 month growth outcomes among children born to mothers with GDM. Subjects/methods: Data on 258 Aboriginal and Torres Strait Islander infants from the PANDORA study born to mothers with normoglycaemia (n = 73), GDM (n = 122), or with pre-existing type 2 diabetes (n = 63) in pregnancy were assessed. Infant weight and BMI growth trajectories according to predominant breastfeeding at 6 months and hyperglycaemia in pregnancy were developed using mixed-effect models and cubic splines. Associations between breastfeeding and 14-month growth outcomes (z-scores: weight-for-age, weight-for-length and BMI) were evaluated using linear regression in a subgroup of infants born to mothers with GDM. Results: Predominantly breastfed infants had lower BMI trajectories compared to those not predominantly breastfed, irrespective of maternal hyperglycaemia in pregnancy status (p

�� 2020 The Authors Background: Globally, rates of hyperglycaemia in pregnancy are highest among Indigenous women. The highest prevalence has been documented among Aboriginal women in the Northern Territory of Australia. Despite knowledge of this for over two decades, there has been very limited examination of the specific needs and experiences of Aboriginal women regarding this condition. Question: How do Aboriginal women with hyperglycaemia in pregnancy understand and experience this condition, and how can their care be improved? Methods: A phenomenological methodology underpinned semi-structured in-depth interviews with 35 Aboriginal women and seven health professionals across the Northern Territory. Data were inductively analysed. Findings: The findings revealed that in general, participants in this study could recite simple health messaging regarding diabetes (e.g. ���no sugar���), but many lacked in-depth knowledge and this affected the management of their condition. Nevertheless, many identified pregnancy as a powerful motivator for change, signalling scope to improve health messaging. Women consistently expressed the need for diabetes education that was culturally appropriate, a clear desire for maternity care that was family-centred, based on respectful relationships with the same care provider, and respected Aboriginal ways of knowing and being. Conclusion: Existing health messaging around hyperglycaemia in pregnancy has limited reach with Aboriginal women in the Northern Territory. Reducing the burden of hyperglycaemia in pregnancy among these women requires a sustained commitment to redesign of maternity and diabetes care to incorporate the cultural and social context of women's lives.

Purpose Shared medical appointments (SMAs) may help mitigate some of the barriers for managing obesity in primary care. The primary aim of this systematic review was to measure the effect of weight loss SMAs. Methods Systematic searches using keywords and Medical Subject Headings for overweight, obesity, and SMAs were conducted in the CENTRAL, Medline Complete, PsycINFO, Scopus, CINAHL, EMBASE, and Web of Science databases with no date limits. Risk of bias was assessed using the Effective Health Practice Project Quality Assessment Tool for Quantitative Studies. Results Fifteen studies involving weight loss SMAs in adults and children were identified. Six studies had controls. Inconsistency in reporting weight loss or weight change in controlled studies meant that data could not be pooled for meta-analysis. Results from individual studies indicated that SMAs can support adult patients to achieve significant weight loss. Women and older adults were more likely to take up SMA invitations. Results from the 5 studies involving children were less conclusive. Studies involving participants of a higher socioeconomic status tended to report lower attrition than studies involving participants who experienced disadvantage. These findings should be interpreted with caution as all but 1 included study was assessed as being weak in quality. Conclusions Overall, SMAs may be of benefit to address obesity in primary care, particularly for women and older adults. Appropriately designed prospective and controlled studies are required to engage their target audience and to assess whether SMAs are superior to other weight loss options in primary care.

Polycystic ovary syndrome (PCOS) is a common and complex endocrinopathy affecting reproductive-age women with a reported prevalence of 8 to 13%. To address the knowledge, practice, consumer satisfaction, and research gaps, an international research collaboration was formed to develop the first “International Evidence-Based Guideline for the Assessment and Management of Polycystic Ovary Syndrome (2018).” This article describes an effective research translation program to disseminate the guideline internationally to women and health providers. To date, this had led to 75,197 views and almost 36,000 downloads of the PCOS guideline, and 43,000 views and 10,600 downloads of a suite of PCOS resources. AskPCOS app, the first freely accessible, evidence-based PCOS app, has 9,910 users (between 400 and 800 users per month), 23,447 sessions, and 87,801 screen viewings. Fifty-four percent of returning users are from across 137 countries, with the most users in Australia, the United States, the United Kingdom, the Netherlands, and India. Extensive global uptake of the PCOS guideline and compendium of resources was augmented by extensive formative consumer and health professional consultation, end-user engagement across the evidence-creation spectrum, co-design, and quality improvement.

ObjectiveTo examine SARS-CoV-2 vaccine confidence, attitudes and intentions in Australian adults.MethodsNationwide survey in February-March 2021 of adults representative across sex, age and location. Vaccine uptake and a range of putative drivers of uptake, including vaccine confidence, socioeconomic status, and sources of trust, were examined using logistic and Bayesian regressions for vaccines generally and for SARS-CoV-2 vaccines.ResultsOverall 1,166 surveys were collected from participants aged 18-90 years (mean 52, SD of 19). Seventy-eight percent reported being likely to receive a vaccine against COVID-19. Higher SARS-CoV-2 vaccine intentions were associated with: increasing age (OR: 1.04 95%CI [1.03-1.044]), being male (OR: 1.37, 95% CI [1.08 – 1.72]), residing in the least disadvantaged area quintile (OR: 2.27 95%CI [1.53 – 3.37]) and a self-perceived high risk of getting COVID-19 (OR: 1.52 95% CI [1.08 – 2.14]). However, 72% of participants did not believe that they were at a high risk of getting COVID-19. Findings regarding vaccines in general were similar except there were no sex differences. For both the SARS-CoV-2 vaccine and vaccines in general, there were no differences in intentions to vaccinate as a function of education level, perceived income level, and rurality. Knowing that the vaccine is safe and effective, and that getting vaccinated will protect others, trusting the company that made it and getting vaccination recommended by a doctor were reported to influence a large proportion of the study cohort to uptake the SARS-CoV-2 vaccine. Seventy-eight percent reported the intent to continue engaging in virus-protecting behaviours (mask wearing, social distancing etc.) post-vaccine.ConclusionsSeventy-eight percent of Australians are likely to receive a SARS-CoV-2 vaccine. Key influencing factors identified in this study (e.g. knowing that the vaccine is safe and effective, getting a doctor’s recommendation to get vaccinated) can be used to inform public health messaging to enhance vaccination rates.Strengths and limitations of this studyThis research captured a large, representative sample of the adult Australian population across age, sex, location, and socioeconomic status.We have self-reported Australian uptake intentions and attitudes on general vaccines and COVID-19 vaccine, and intent to continue engaging in virus-protecting behaviours (mask wearing, social distancing etc.) post SARS-CoV-2 vaccine.We examine a range of drivers and factors that may influence intent to get the SARS-CoV-2 vaccine uptake, including vaccine confidence, demographics and socioeconomic status.The survey is based on established behavioural theories, and is the Australian arm of the international iCARE survey which to date has collected global comparative information from over 90,000 respondents in 140 countries.Our survey was only available in English, which may have led to an underrepresentation of ethnic groups, and participation was voluntary, so our sample may be prone to selection bias from those with more interest or engagement in COVID-19.

BackgroundAs of June 2020, there were more than 79.5 million people displaced from their homes globally. Despite significantly different lived experiences, health literacy is poor within most displaced communities, contributing to low awareness and uptake of healthcare services and poor health outcomes as a result. Co-designing health interventions with communities is not a new concept however it is experiencing a significant increase in interest and support within the global health movement and areas of health equity in particular. This scoping review examines the current literature and gaps related to co-designing health interventions with refugees in order to increase health literacy; provide health services; and/or build quantitative data on health needs specific to refugee communities.MethodsThe following three questions were drafted and incorporated into a PICO framework.1. What literature exists surrounding co-designing health interventions with refugee populations?2. What effect (if any) do existing co-designed health interventions have on health outcomes (as defined above) within refugee populations?3. What gaps persist in co-designing health interventions with refugee communities? Key search terms were developed aiming to locate academic literature located within a Venn diagram of three categories: health, refugees and co-design. ResultsCombined searches uncovered a total of 1,804 articles following removal of duplications. 1,750 articles were excluded following screening of title and abstract leaving a shortlist of 54 articles. Only 10 of these articles met PICO criteria and nine of these focused exclusively on co-designing health interventions with refugee populations applied qualitative techniques. Only one article addressed all three health outcomes listed in the inclusion criteria above and half the articles did not discuss intervention outcomes or include any form of process evaluation.ConclusionsThis scoping review presents an opportunity to explore the intersection of collaborative design and health innovation with refugee communities. To ensure health interventions improve health outcomes, communities directly affected by displacement must be supported to authentically participate in, and where possible lead, efforts to co-design within this context. Future research efforts should expand to focus on evaluating the outcomes of ethical, meaningful and representative collaboration.

Background Women are underrepresented in healthcare leadership, yet evidence on impactful organisational strategies, practices and policies that advance women's careers are limited. We aimed to explore these across sectors to gain insight into measurably advancing women in leadership in healthcare. Methods A systematic review was performed across Medline via OVID; Medline in-process and other non-indexed citations via OVID; PsycINFO and SCOPUS from January 2000 to March 2021. Methods are outlined in a published protocol registered a priori on PROSPERO (CRD42020162115). Eligible studies reported on organisational interventions for advancing women in leadership with at least one measurable outcome. Studies were assessed independently by two reviewers. Identified interventions were organised into categories and meta-synthesis was completed following the ‘ENhancing Transparency in REporting the synthesis of Qualitative research’ (ENTREQ) statement. Findings There were 91 eligible studies from 6 continents with 40 quantitative, 38 qualitative and 13 mixed methods studies. These spanned academia, health, government, sports, hospitality, finance and information technology sectors, with around half of studies in health and academia. Sample size, career stage and outcomes ranged broadly. Potentially effective interventions consistently reported that organisational leadership, commitment and accountability were key drivers of organisational change. Organisational intervention categories included i) organisational processes; ii) awareness and engagement; iii) mentoring and networking; iv) leadership development; and v) support tools. A descriptive meta-synthesis of detailed strategies, policies and practices within these categories was completed. Interpretation This review provides an evidence base on organisational interventions for advancing women in leadership across diverse settings, with lessons for healthcare. It transcends the focus on the individual to target organisational change, capturing measurable change across intervention categories. This work directly informs a national initiative with international links, to enable women to achieve their career goals in healthcare and moves beyond the focus on barriers to solutions. Funding Epworth Health, Cabrini and Monash University provided scholarships for MM and AM. HT is funded by an NHMRC / MRFF Practitioner Fellowship, JB by an NHMRC fellowship and HS by a Monash Warwick University Professorship.

Background Lifestyle behaviours may worsen following childbirth due to barriers such as time constraints and reduced prioritization of personal health. We therefore aimed to assess the patterns of change in weight and lifestyle behaviours following childbirth in a longitudinal community-based cohort. Methods Data from surveys 3 and 5 (ages 25-30 and 31-36 years) of the 1973-8 birth cohort of the Australian Longitudinal Study on Women’s Health were used. We assessed changes in weight, energy intake, diet (diet quality, macronutrients and micronutrients), physical activity and sitting time in parous women compared to those who remained nulliparous by survey 5 using one-way analysis of covariance. Results Of 4927 nulliparous women at survey 3, 2503 became parous by survey 5. Over 6 years, parous women had an increase in weight (1 kg; 95%CI 0.50, 1.54), higher energy intake (833.3 kJ/day; 95%CI 706.07, 960.52), better diet quality (1.4 units; 95%CI 0.81, 2.08), lower physical activity (-370.5 METmin/day; 95%CI -427.07, -313.87) and less sitting time (-1.8 hours/day; 95%CI -1.93, -1.60) than nulliparous women on adjusted analyses. On stratification of parity, the improvement in diet quality was only present in primiparous women and sitting time decreased with higher parity. Conclusion There is a worsening in weight and some lifestyle behaviours following childbirth in Australian women. While higher parity was associated with further decreases in sitting time, improvements in diet quality were not maintained. Key message Women need support to maintain healthy lifestyle behaviours amidst the challenges of caring for children, particularly with increasing family size.

Background The COVID-19 pandemic is associated with increased psychological distress in Australia and globally. Few studies have examined distress in women, a group vulnerable to experiencing increased financial and child-care stressors during the pandemic. Such epidemiological benchmark data is essential for population monitoring, and can inform policy by highlighting groups at increased risk of mental health burdens. Methods Analysis of women aged 18-50 from a nationally representative survey collected in October 2020 (n = 1005) and the 2017-18 National Health Survey (n = 4267). Trends in the prevalence of very high scores on the Kessler-10, a measure of psychological distress capturing symptoms of affective and anxiety disorders, were compared across the surveys and by sociodemographic characteristics (age, education, socioeconomic status, income, family type and employment change). Results Rates of very high psychological distress were 4.6% in 2017-18 (95% CI = 3.8%-5.4%) to 19.3% in 2020 (95% CI = 16.9%-21.8%), and were greater in 2020 across all sociodemographic subgroups. In 2020, rates were highest in women who experienced employment change (29.8%, 95% CI = 24.1%-35.6%), earned $0-$49,000 annually (25.7, 95% CI = 18.5%-32.9%), and were single with children (24.8%, 95% CI = 16.3%-33.2%). Conclusions Psychological distress has increased in Australian women during the pandemic, especially for those experiencing employment change, with lower incomes, or who are single parents. Findings will be discussed in the conjunction with extant social policies and access to mental health support. Key messages The rate of very high psychological distress has increased fourfold in Australian women during the pandemic.

Background Maternal obesity is associated with health risks for women and their babies and is exacerbated by excess gestational weight gain. The aim of this study was to describe women’s experiences and perspectives in attending a Healthy Pregnancy Service designed to optimise healthy lifestyle and support recommended gestational weight gain for women with obesity. Methods An explanatory sequential mixed methods study design utilised two questionnaires (completed in early and late pregnancy) to quantify feelings, motivation and satisfaction with the service, followed by semi-structured interviews that explored barriers and enablers of behaviour change. Data were analysed separately and then interpreted together. Results Overall, 49 women attending the service completed either questionnaire 1, 2 or both and were included in the analysis. Fourteen women were interviewed. Prior to pregnancy, many women had gained weight and attempted to lose weight independently, and reported they were highly motivated to achieve a healthy lifestyle. During pregnancy, diet changes were reported as easier to make and sustain than exercise changes. Satisfaction with the service was high. Key factors identified in qualitative analysis were: service support enabled change; motivation to change behaviour, social support, barriers to making change (intrinsic, extrinsic and clinic-related), post-partum lifestyle and needs. On integration of data, qualitative and quantitative findings aligned. Conclusions The Healthy Pregnancy service was valued by women. Barriers and enablers to the delivery of an integrated model of maternity care that supported healthy lifestyle and recommended gestational weight gain were identified. These findings have informed and improved implementation and further scale up of this successful service model, integrating healthy lifestyle into routine antenatal care of women with obesity. Trial registration This trial is registered with the Australian New Zealand Clinical Trials Registry (no.12620000985987). Registration date 30/09/2020, retrospectively registered. http://www.anzctr.org.au/

To assess associations of hyperglycemia in pregnancy with the risk of postpartum hemorrhage (PPH) in a prospective cohort of Indigenous and non-Indigenous women, compared with normoglycemia.Data were from 1102 (48% Indigenous) women of the Pregnancy And Neonatal Diabetes Outcomes in Remote Australia (PANDORA) Study. Age-adjusted associations of gestational diabetes mellitus (GDM) or pre-existing type 2 diabetes mellitus (T2DM), obstetric and demographic covariables with PPH (blood loss ≥500 ml) were assessed using logistic regression. Multivariable-adjusted models included Indigenous ethnicity, diabetes type and their interaction.A higher proportion of Indigenous women developed PPH than non-Indigenous women (32% versus 22%; P 0.001). Compared with non-Indigenous women with normoglycemia, risks of PPH for Indigenous women with GDM or T2DM were higher (odds ratio [OR] 1.83, 95% confidence intervals [CI] 1.11-3.02, and OR 1.72, 95% CI 0.99-3.00 after age adjustment, OR 1.84, 95% CI 1.06-3.19, and OR 1.33, 95% CI 0.70-2.54 after adjustment for school education and delivery mode, and OR 1.62, 95% CI 0.95-2.77, and OR 0.99, 95% CI 0.53-1.86 after adjustment for birth weight). Importantly, Indigenous women without hyperglycemia in pregnancy were not at increased risk of PPH.The significantly higher rates of PPH experienced by Indigenous women compared with non-Indigenous women may be explained by a greater effect of GDM among Indigenous women that was only partly accounted for by birth weight.

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among reproductive-aged women; however, to date there has been no synthesis of the burden of PCOS specifically among indigenous women. We aimed to systematically identify and collate studies reporting prevalence and clinical features of PCOS among indigenous women worldwide. We performed a comprehensive search of six databases (Ovid MEDLINE, MEDLINE In Process & Other Non-Indexed Citations, EMBASE, EBM reviews, CINAHL, and SCOPUS) supplemented by gray literature searches and the screening of reference lists. A narrative synthesis was conducted. Fourteen studies met inclusion criteria; however, one was excluded as it assessed only children and adolescents younger than 15 years, with limited clinical relevance. Studies examined indigenous women from Australia, Sri Lanka, New Zealand, and the United States. Prevalence of PCOS was reported in only four studies and ranged from 3.05% for women in Sri Lanka to 26% for women in Australia. All included studies reported on at least one clinical feature of PCOS. Of the studies that reported on a comparison group from the same country, there was evidence of more severe features in indigenous women from New Zealand and the United States. The limited evidence available warrants further investigation of the burden of PCOS in indigenous women to build the knowledge base for effective and culturally relevant management of this condition.