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

Background: There is growing evidence from Australia and overseas that the care provided in hospital in the early postnatal period is less than ideal for both women and care providers. Many health services face increasing pressure on hospital beds and have limited physical space available to care for mothers and their babies. We aimed to gain a more in-depth understanding of women's views, expectations and experiences of early postnatal care.Methods: We conducted focus groups in rural and metropolitan Victoria, Australia in 2006. Fifty-two people participated in eight focus groups and four interviews. Participants included eight pregnant women, of whom seven were pregnant with their first baby; 42 women who were in the postpartum period (some up to twelve months after the birth of their baby); and two partners. All participants were fluent in English. Focus group guides were developed specifically for the study and explored participants' experiences and/or expectations of early postnatal care in hospital and at home, with an emphasis on length of hospital stay, professional and social support, continuity of care, and rest. Discussions were audio-taped and transcribed verbatim. A thematic network was constructed to describe and connect categories with emerging basic, organizing, and global themes.Results: Global themes that emerged were: anxiety and/or fear; and the transition to motherhood and parenting. The needs of first time mothers were considered to be different to the needs of women who had already experienced motherhood. The women in this study were generally concerned about the safety of their new baby, and lacked confidence in themselves as new mothers regarding their ability to care for their baby. There was a consistent view that the physical presence and availability of professional support helped alleviate these concerns, and this was especially the case for women having a first baby.Conclusion: Women have anxieties and fears around early parenting and their changing role, and may consider that the physical availability of professional care providers will help during this time. Care providers should be cognisant of these potential issues. It is crucial that women's concerns and needs be considered when service delivery changes are planned. If anxiety around new parenting is a predominant view then care providers need to recognise this and ensure care is individualised to address each woman's/families particular concerns. [ABSTRACT FROM AUTHOR]

Background: Women in rural Australia often have limited maternity care options available, and in Victoria, like many Australian states, numerous small hospitals no longer offer birthing services., Aim: To evaluate women's views and experiences of maternity care at a local rural hospital that re-established birthing services with a Midwifery Group Practice (MGP) model of maternity care., Methods: Women who booked into the new MGP model from May 2021 to June 2022 were invited to complete an anonymous online survey and participate in an optional additional semi-structured interview to explore their views and experiences. Descriptive statistics were used for quantitative data, and open-ended survey and interview responses were analysed using a general inductive approach., Findings: Sixty-seven percent (44/66) of women completed the survey and five also completed an interview. Women were highly satisfied with the care they received. They felt respected, empowered, and had a sense of agency throughout their pregnancies, labour and birth, and post-birth. They reported low levels of anxiety during labour and birth, and felt that they coped physically and emotionally better than they anticipated. They felt well supported by midwives and highly valued the continuity of care within the MGP model., Conclusion: Women's voices play a critical role in informing maternity care provision, particularly for those in rural communities who may have limited access to care options. The findings support and expand on existing research regarding the value of midwifery continuity of care models, and can inform other rural maternity services in introducing similar models., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

It is estimated that over 1 billion people worldwide have a disability. In Australia, 9% of women of childbearing age have a disability, but data on disability status for women accessing maternity services are not routinely collected and data collection processes are inconsistent. Maternal disability may affect perinatal outcomes, but to understand what factors might be amenable to interventions to improve outcomes, accurate data collection on disability status is essential. This opinion piece reflects on disability identification within maternity services in Australia, identifying areas for policy and practice change., (© 2023 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Introduction: Postnatal depression affects up to one in six new mothers in Australia each year, with significant impacts on the woman and her family. Prevention strategies can be complicated by a woman's reluctance to seek professional help. Peer support is a promising but inadequately tested early intervention. Very few trials have reported on the efficacy of peer support in the perinatal period and no study has been undertaken in Australia. We will explore if proactive telephone-based peer (mother-to-mother) support, provided to women identified as being at high risk of postnatal depression, impacts on clinically significant depressive symptomatology at 6 months postpartum., Methods and Analysis: This is a protocol for a single-blinded, multi-centre, randomised controlled trial conducted in Melbourne, Australia. Eligible women will be recruited from either the postnatal units of two maternity hospitals, or around 4 weeks postpartum at maternal and child health centres within two metropolitan council areas. A total of 1060 (530/group) women will be recruited and randomly allocated (1:1 ratio) to either-usual care, to receive the standard community postpartum services available to them, or the intervention group, to receive proactive telephone-based support from a peer volunteer for 6 months, in addition to standard community services., Primary Outcome: clinically significant depressive symptomatology at 6 months postpartum as measured using the Edinburgh Postnatal Depression Scale., Secondary Outcomes: symptoms of anxiety and/or stress, health-related quality of life, loneliness, perception of partner support, self-rated parenting, child health and development, infant feeding and health service use. The cost-effectiveness of the intervention relative to standard care will also be assessed., Ethics and Dissemination: Ethics approval has been obtained from La Trobe University, St. Vincent's Hospital, the Royal Women's Hospital, Northern Health, Victorian Department of Health and Human Services and Victorian Department of Education and Training. Written informed consent will be obtained from all participants before randomisation. Trial results will be disseminated through peer-reviewed publications, conference presentations and a higher degree thesis., Trial Registration Number: ACTRN12619000684123; Australian New Zealand Clinical Trials Registry., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: In Australia, there is a lack of accurate data on midwifery workforce staffing and skill mix, which in turn hinders workforce policy and planning., Aim: To describe the current staffing levels of the midwifery workforce in Victoria, Australia, explore workforce challenges and assess the impact of COVID-19 pandemic on staffing., Design: Cross-sectional., Methods: Midwifery managers in all public and private maternity services in Victoria, Australia were invited to complete a survey exploring midwifery staffing numbers and adequacy. Topics explored included midwifery turnover, recruitment, and skill mix. Descriptive statistics were used., Findings: The survey was open March to October 2021, and 56 % (38/68) of managers responded. Of these, 76 % reported inadequate midwifery staff levels, with deficits ranging from one to 19 estimated Full-Time Equivalent (EFT) midwives, with a combined total deficit of 135 EFT. In the 12 months prior to the survey, 73 % of services had found it difficult to recruit midwives, with increased difficulty during the COVID-19 pandemic. Managers were concerned about retaining and recruiting 'experienced' midwives due to an ageing workforce and high turnover due to work/life imbalance and job dissatisfaction. These issues have led to a predominantly early career midwifery workforce and created concern about skill mix., Conclusion: Victorian maternity services have a midwifery workforce shortage and are experiencing significant skill mix issues. The pandemic has exacerbated these considerable gaps in the workforce. Urgent implementation of retention and recruitment schemes are needed, along with strategies to improve the working conditions for the current workforce., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Australia has one of the lowest perinatal morbidity and mortality rates in the world, however a cluster of perinatal deaths at a regional health service in the state of Victoria in 2015 led to state-wide reforms, including the introduction of the Maternity and Newborn Emergencies (MANE) program. MANE was a 2-day interprofessional maternity education program delivered by external expert facilitators to rural and regional Victorian maternity service providers. An independent evaluation found that the MANE program improved the confidence and knowledge of clinicians in managing obstetric emergencies and resulted in changes to clinical practice. While there is a large volume of evidence that supports the use of interprofessional education in improving clinicians' clinical practice, the impact of these programs on the overall safety culture of a health service has been less studied. Managers and educators have an important role in promoting the safety culture and clinical governance of the heath service. The aim of this study, therefore, was to explore Victorian rural and regional maternity managers' and educators' views and experiences of the MANE program., Methods: Maternity managers and educators from the 17 regional and rural health services across Victoria that received the MANE program during 2018 and 2019 were invited to participate. Semi-structured interviews using mostly open-ended questions (and with a small number of fixed response questions) were undertaken. Qualitative data were transcribed verbatim and analysed thematically. Descriptive statistics were used for quantitative data., Results: Twenty-one maternity managers and educators from the 17 health services participated in the interviews. Overall, participants viewed the MANE program positively. Four themes were identified: the value of external facilitation in providing obstetric emergency training; improved awareness and understanding of clinical governance; improved clinical practice; and the importance of maintaining the program. Participants agreed that MANE had improved the confidence (94%) and skills (94%) of clinicians in managing obstetric emergencies, as well as confidence to escalate concerns (94%), and most agreed that it had improved clinical practice (70%) and teamwork among attendees (82%)., Conclusion: Maternity managers and educators were positive about MANE; they considered that it contributed to improving factors that impact the safety culture of health services, with delivery by external experts considered to be particularly important. Given the crucial role of maternity managers and educators on safety culture in health services, as well in program facilitation, these findings are important for future planning of maternity education programs across the state., Trial Registration: Trial registration was not required for this study., (© 2023. The Author(s).)

Problem: Little is known about midwives' views and wellbeing when working in an all-risk caseload model., Background: Between March 2017 and December 2020 three maternity services in Victoria, Australia implemented culturally responsive caseload models for women having a First Nations baby., Aim: Explore the views, experiences and wellbeing of midwives working in an all-risk culturally responsive model for First Nations families compared to midwives in standard caseload models in the same services., Methods: A survey was sent to all midwives in the culturally responsive (CR) model six-months and two years after commencement (or on exit), and to standard caseload (SC) midwives two years after the culturally responsive model commenced. Measures used included the Midwifery Process Questionnaire and Copenhagen Burnout Inventory (CBI)., Findings: 35 caseload midwives (19 CR, 16 SC) participated. Both groups reported positive attitudes towards their professional role, trending towards higher median levels of satisfaction for the culturally responsive midwives. Midwives valued building close relationships with women and providing continuity of care. Around half reported difficulty maintaining work-life balance, however almost all preferred the flexible hours to shift work. All agreed that a reduced caseload is needed for an all-risk model and that supports around the model (e.g. nominated social workers, obstetricians) are important. Mean CBI scores showed no burnout in either group, with small numbers of individuals having burnout in both groups., Discussion and Conclusion: Midwives were highly satisfied working in both caseload models, but decreased caseloads and more organisational supports are needed in all-risk models., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: The 'Ringing Up about Breastfeeding earlY' (RUBY) randomised controlled trial showed increased breastfeeding at 6 months in participants who received the proactive telephone-based peer support breastfeeding intervention compared with participants allocated to receive standard care and supports. The present study aimed to evaluate if the intervention was cost-effective., Design: A within-trial cost-effectiveness analysis., Setting: Three metropolitan maternity services in Melbourne, Victoria, Australia., Participants: First time mothers intending to breastfeed their infant (1152) and peer volunteers (246)., Intervention: The intervention comprised proactive telephone-based support from a peer volunteer from early postpartum up to 6 months. Participants were allocated to usual care (n=578) or the intervention (n=574)., Main Outcome Measures: Costs during a 6-month follow-up period including individual healthcare, breastfeeding support and intervention costs in all participants, and an incremental cost-effectiveness ratio., Results: Costs per mother supported were valued at $263.75 (or $90.33 excluding costs of donated volunteer time). There was no difference between the two arms in costs for infant and mothers in healthcare and breastfeeding support costs. These figures result in an incremental cost-effectiveness ratio of $4146 ($1393 if volunteer time excluded) per additional mother breast feeding at 6 months., Conclusion: Considering the significant improvement in breastfeeding outcomes, this intervention is potentially cost-effective. These findings, along with the high value placed on the intervention by women and peer volunteers provides robust evidence to upscale the implementation of this intervention., Trial Registration Number: ACTRN12612001024831., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Policies and strategies addressing the health inequities experienced by First Nations peoples are critical to ensuring the gap in outcomes between First Nations and non-Indigenous peoples is closed. The identification of First Nations peoples is vital to enable the delivery of culturally safe and sensitive health care. Complete and accurate health data are essential for funding and evaluation of such initiatives., Aims: To describe the processes used and accuracy of identification and documentation of First Nations mothers and babies during the period of the implementation of a culturally responsive caseload model of maternity care at three major metropolitan maternity services in Melbourne, Australia., Materials and Methods: A cross-sectional study was conducted using administrative and clinical data., Results: There was variation in when and how First Nations identification was asked and documented for mothers and babies. Errors included 14% of First Nations mothers not identified at the first booking appointment, 5% not identified until after the birth and 11% of First Nations babies not identified in the Victorian Perinatal Data Collection documentation. Changes to documentation and staff education were implemented to improve identification and reduce inaccuracies., Conclusions: To improve disparities in health outcomes, mainstream health services must respond to the needs of First Nations peoples, but improved care first requires accurate identification and documentation of First Nations peoples. Implementing and maintaining accuracy in collection and documentation of First Nations status is essential for health services to provide timely and appropriate care to First Nations people and to support and grow culturally appropriate and safe services., (© 2022 The Authors. Australian and New Zealand Journal of Obstetrics and Gynaecology published by John Wiley & Sons Australia, Ltd on behalf of Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: Australian Aboriginal and Torres Strait Islander (hereafter referred to as Aboriginal) women breastfeed at lower rates than non-Aboriginal women. Little is known about factors associated with breastfeeding specific to Aboriginal women and infants., Aim: Determine the protective and risk factors associated with breastfeeding for Aboriginal women in Australia., Methods: CINAHL, Medline, EMBASE, SCOPUS, PsycINFO, and the Cochrane library were searched for peer-reviewed literature published between 1995 and 2021. Quantitative studies written in English reporting protective and risk factors associated with breastfeeding for Aboriginal women or women having an Aboriginal infant were included. Ten percent of papers were co-screened, and two reviewers completed data extraction. Narrative data synthesis was used., Findings: The initial search identified 12,091 records, with 31 full text studies retrieved, and 17 reports from 14 studies met inclusion criteria. Protective factors included living in a remote area, attending an Aboriginal-specific service, attending a regional service, higher levels of education attainment, increased maternal age, living in larger households, being partnered, and having a higher reported number of stressful events and social health issues. The identified risk factors were smoking in pregnancy, admission to SCN or NICU, and being multiparous., Conclusion: This review identified factors associated with breastfeeding for Aboriginal women. Government focus, support, and consistent funding are required to plan and implement evidence-based interventions and services for Aboriginal women and infants in urban, rural, remote, and very remote locations. Rigorous research is required to understand the Aboriginal-specific factors associated with breastfeeding to improve rates and health outcomes for Aboriginal women and infants., (Copyright © 2022 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Objectives: There is an urgent need to improve breast feeding rates for Australian First Nations (Aboriginal and Torres Strait Islander) infants. We explored breast feeding outcomes of women having a First Nations infant at three sites that introduced a culturally specific continuity of midwife care model., Design: Women having a First Nations infant booking for pregnancy care between March 2017 and November 2020 were invited to participate. Surveys at recruitment and 3 months post partum were developed with input from the First Nations Advisory Committee. We explored breast feeding intention, initiation, maintenance and reasons for stopping and factors associated with breast feeding., Setting: Three tertiary maternity services in Melbourne, Australia., Participants: Of 479/926 eligible women approached, 343 (72%) completed the recruitment survey, and 213/343 (62%) the postnatal survey., Outcomes: Primary: breast feeding initiation and maintenance. Secondary: breast feeding intention and reasons for stopping breast feeding., Results: Most women (298, 87%) received the culturally specific model. Breast feeding initiation (96%, 95% CI 0.93 to 0.98) was high. At 3 months, 71% were giving 'any' (95% CI 0.65 to 0.78) and 48% were giving 'only' breast milk (95% CI 0.41 to 0.55). Intending to breast feed 6 months (Adj OR 'any': 2.69, 95% CI 1.29 to 5.60; 'only': 2.22, 95% CI 1.20 to 4.12), and not smoking in pregnancy (Adj OR 'any': 2.48, 95% CI 1.05 to 5.86; 'only': 4.05, 95% CI 1.54 to 10.69) were associated with higher odds. Lower education (Adj OR 'any': 0.36, 95% CI 0.13 to 0.98; 'only': 0.50, 95% CI 0.26 to 0.96) and government benefits as the main household income (Adj OR 'any': 0.26, 95% CI 0.11 to 0.58) with lower odds., Conclusions: Breast feeding rates were high in the context of service-wide change. Our findings strengthen the evidence that culturally specific continuity models improve breast feeding outcomes for First Nations women and infants. We recommend implementing and upscaling First Nations specific midwifery continuity models within mainstream hospitals in Australia as a strategy to improve breast feeding., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Australian Aboriginal and Torres Strait Islander (referred to hereafter as Aboriginal) women breastfeed at lower rates than non-Aboriginal women, and rates vary across and within Aboriginal populations., Aim: To determine rates of breastfeeding initiation and maintenance and compare individually collected survey data with existing routinely collected state and national breastfeeding data for Aboriginal women., Methods: CINAHL, Medline, EMBASE, SCOPUS, PsycINFO, and the Cochrane library were searched for peer-reviewed literature published between 1995 and 2021. Quantitative studies written in English and reporting breastfeeding for Aboriginal women or women having an Aboriginal infant were included. Screening and quality assessment included co-screening 10% of papers. Two reviewers completed data extraction. A proportional meta-analysis was undertaken for breastfeeding initiation and narrative data synthesis used to summarise breastfeeding maintenance., Findings: The initial search identified 12,091 records, with 31 full text studies retrieved, and 27 reports from 22 studies met inclusion criteria. Breastfeeding initiation was 78% (95% CI 0.71, 0.84), however, rates were lower than non-Aboriginal women. Maintenance ranged between one week and five years. Rates and definitions varied significantly between studies, with inconsistencies in government collection and reporting of breastfeeding., Conclusion: Significant variation in definitions and reporting make comparisons difficult. Breastfeeding rates were below recommended targets. Future pattern and trend analyses require standardised measures and definitions. Current collection and reporting of breastfeeding data, particularly routinely collected state-based data, is inadequate to present an accurate picture of current breastfeeding in Australia for Aboriginal women and infants, and to effectively inform interventions and policies., Competing Interests: Conflict of interest None declared., (Copyright © 2022 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Introduction: Almost 78 000 women gave birth in the state of Victoria, Australia, in 2019. While most births occurred in metropolitan Melbourne and large regional centres, a significant proportion of women birthed in rural services. In late 2016, to support clinicians to recognise and respond to clinical deterioration, the Victorian government mandated provision of an emergency training programme, called Maternity and Newborn Emergencies (MANE), to rural and regional maternity services across the state. This paper describes the evaluation of MANE., Design and Setting: A quasi-experimental study design was used; the Kirkpatrick Evaluation Model provided the framework., Participants: Participants came from the 17 rural and regional Victorian maternity services who received MANE in 2018 and/or 2019., Outcome Measures: Baseline data were collected from MANE attendees before MANE delivery, and at four time points up to 12 months post-delivery. Clinicians' knowledge of the MANE learning objectives, and confidence ratings regarding the emergencies covered in MANE were evaluated. The Safety Attitudes Questionnaire (SAQ) assessed safety climate pre-MANE and 6 months post-MANE among all maternity providers at the sites., Results: Immediately post-MANE, most attendees reported increased confidence to escalate clinical concerns (n=251/259). Knowledge in the non-technical and practical aspects of the programme increased. Management of perinatal emergencies was viewed as equally stressful pre-MANE and post-MANE, but confidence to manage these emergencies increased post-delivery. Pre-MANE SAQ scores showed consistently strong and poor performing services. Six months post-MANE, some services showed improvements in SAQ scores indicative of improved safety climate., Conclusion: MANE delivery resulted in both short-term and sustained improvements in knowledge of, and confidence in, maternity emergencies. Further investigation of the SAQ across Victoria may facilitate identification of services with a poor safety climate who could benefit from frequent targeted interventions (such as the MANE programme) at these sites., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Strategies to improve outcomes for Australian First Nations mothers and babies are urgently needed. Caseload midwifery, where women have midwife-led continuity throughout pregnancy, labour, birth and the early postnatal period, is associated with substantially better perinatal health outcomes, but few First Nations women receive it. We assessed the capacity of four maternity services in Victoria, Australia, to implement, embed, and sustain a culturally responsive caseload midwifery service., Methods: A prospective, non-randomised research translational study design was used. Site specific culturally responsive caseload models were developed by site working groups in partnership with their First Nations health units and the Victorian Aboriginal Community Controlled Health Organisation. The primary outcome was to increase the proportion of women having a First Nations baby proactively offered and receiving caseload midwifery as measured before and after programme implementation. The study was conducted in Melbourne, Australia. Data collection commenced at the Royal Women's Hospital on 06/03/2017, Joan Kirner Women's and Children's Hospital 01/10/2017 and Mercy Hospital for Women 16/04/2018, with data collection completed at all sites on 31/12/2020., Findings: The model was successfully implemented in three major metropolitan maternity services between 2017 and 2020. Prior to this, over a similar timeframe, only 5.8% of First Nations women ( n  = 34) had ever received caseload midwifery at the three sites combined. Of 844 women offered the model, 90% ( n  = 758) accepted it, of whom 89% ( n  = 663) received it. Another 40 women received standard caseload. Factors including ongoing staffing crises, prevented the fourth site, in regional Victoria, implementing the model., Interpretation: Key enablers included co-design of the study and programme implementation with First Nations people, staff cultural competency training, identification of First Nations women (and babies), and regular engagement between caseload midwives and First Nations hospital and community teams. Further work should include a focus on addressing cultural and workforce barriers to implementation of culturally responsive caseload midwifery in regional areas., Funding: Partnership Grant (# 1110640), Australian National Health and Medical Research Council and La Trobe University., Competing Interests: We declare there are no competing interests., (© 2022 The Author(s).)

Background: The RUBY randomised controlled trial was found to be effective in promoting breastfeeding continuation, in the setting of a high income country, through a program of proactive telephone-based peer support in the first 6 months postpartum. This paper explores women's experiences of receiving the peer support intervention in the RUBY trial., Methods: Ten in-depth, face-to-face interviews were conducted between December 2015 and November 2016 in Metropolitan Melbourne, and regional Victoria, Australia. Participants were women who received the peer support intervention in the RUBY trial and were between 11 and 15 months postpartum at the time of interview. Interviews were underpinned by social support theories and were analysed using inductive thematic analysis., Results: A global theme of 'non-judgemental support and guidance' was identified, which included five organising themes. Four of the organising themes centred on the support from the peer, in which women felt the support was a 'positive experience with empathy and understanding', 'non-judgemental', 'practical advice', and a 'social connection that was more than just breastfeeding'. In contrast to the support from peers was the theme 'not all support from family and friends is supportive'., Conclusion: Participants, including those who considered that they had adequate and available family and friend support for breastfeeding, valued and appreciated the non-judgemental, empathetic and understanding support from peers. This support, facilitated by the anonymity of the telephone-based program, allowed open and honest conversations, normalising women's experiences and helping them feel less alone in their challenges with breastfeeding and transition to motherhood. These findings can inform the design, and upscaling, of innovative and sustainable peer support models, ensuring delivery of effective and engaging support with a broad population reach., (© 2022. The Author(s).)

Objective: There are a wide variety of information sources available during pregnancy and the early parenting period, but limited understanding of their usefulness, particularly for partners. We explored the views of both women and their partners regarding sources of information, their frequency of use, and their preferred formats., Design and Setting: Data were collected as part of a large cluster randomised controlled trial at a tertiary maternity hospital in 2015-2016, in Melbourne, Australia. The overall evaluation was of a parenting kit ('Growing Together'), an evidence-based information source for prospective and new parents covering the period from conception until one year postpartum. This paper uses data collected from women when their baby was two months of age, and women's partners when the baby was six months of age, via postal or online survey., Participants: Women were eligible if they booked for pregnancy care at The Royal Women's Hospital during the recruitment period, were having their first baby, able to read and speak English without an interpreter, and <30 weeks pregnant at their first hospital appointment (n = 1034). All eligible women were included unless they opted out., Measurements and Findings: In total 92 women were excluded. Of the women sent the two-month survey, 42% (392/941) responded. Partner surveys were returned by 252/791 partners (32%). Respondents received information from a range of sources, most frequently face to face from health professionals through childbirth education or midwife discussion/education, followed by friends and family members. Information received from a health professional was also reported as being the most useful. For both women and their partners, the most important factor related to information was that it was from a trusted and reliable source., Key Conclusions and Implications for Practice: Women and their partners highlighted the importance of quality and access to evidence based resources and information. The internet is frequently favoured by women and their partners due to its convenience, accessibility, and timely access to information. Overall, women and their partners reported information directly from a health care professional to be the most useful and health services should ensure that women and their partners have adequate access to their health care professional., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: The RUBY randomised controlled trial demonstrated the benefit of proactive telephone peer support in promoting breastfeeding continuation in a setting with high breastfeeding initiation, where typically this is difficult to achieve. This paper describes the implementation and delivery of the peer support intervention with a focus on recruitment, training, and support of peer volunteers, and includes a description of the key components of the calls., Methods: Data collection occurred between December 2012 and June 2016 in Melbourne, Australia. Volunteers completed enrolment forms at the training session and recorded data related to each call in a Call Log maintained for each mother supported. Data were summarised using descriptive statistics and responses to open-ended questions analysed using content analysis., Results: A total of 693 women expressed interest in the peer support role, with 246 completing training, that is, 95% of whom supported at least one mother. Each supported a mean of two mothers (range 1 to 11). Training session topics included respecting individual values, using positive language, confidence building, active listening, empathetic support, and normal baby behaviour. There were 518 periods of support where at least one call was made between a volunteer and a mother to whom she was allocated. Of the 518 periods of support, 359 Call Logs (69%) were returned. The 359 call logs recorded a total of 2398 calls between peers and mothers. Call length median duration was 12 min (range 1 to 111 min). Volunteers perceived the most valued aspects of the calls were the provsion of 'general emotional support' (51%) and 'general information/discussion about breastfeeding' (44%). During the first call, mothers raised questions about 'nipple pain/ damage' (24%) and 'general breastfeeding information' (23%). At ≥12 weeks postpartum, issues raised related to 'normal infant behaviour' (22%), 'feed frequency' (16%), and 'general breastfeeding information' (15%). Volunteers referred women to other resources during 28% of calls, most commonly to the Australian Breastfeeding Association., Conclusions: Our findings demonstrate that the RUBY trial was feasible and sustainable in terms of recruiting volunteers who were willing to participate in training and who proceeded to provide peer support. Call content was responsive to the evolving breastfeeding information needs of mothers and the provision of emotional support was perceived by volunteers to be important., Trial Registration: Australian New Zealand Clinical Trials Registry, ACTRN 12612001024831 ., (© 2021. The Author(s).)

Objective: To evaluate new mothers' experiences of infant feeding support., Design: A postal survey developed for this study was sent to all new mothers in ten local government areas in Victoria, Australia when their baby was six months of age. Questions explored infant feeding methods, feeding support services, and experiences of infant feeding support. This survey made up one component of the Supporting breastfeeding In Local Communities (SILC) cluster randomised controlled trial., Findings: 997/4127 women (24%) completed the survey between 15 April 2013 and 31 July 2013. Women received infant feeding support from multiple sources, including professionals, family members, and peers. Overall, 88% reported receiving adequate infant feeding support. Women who reported not receiving adequate infant feeding support were less likely to be giving any breast milk at six months compared to those reporting adequate support (OR = 0.59; 95% CI 0.40, 0.88). Adjusting for breastfeeding intention and parity did not alter the association (Adj. OR = 0.60; 95% CI 0.40, 0.90). Women were most satisfied when they received accessible, available, consistent professional infant feeding support provided in a non-judgemental and reassuring way. Women were dissatisfied when there were barriers restricting access to support, or when they received conflicting advice or support that made them feel guilty, pressured or judged., Key Conclusions: Regardless of infant feeding method, women wanted accessible, non-judgemental support. Given that receiving adequate support was associated with more breast milk feeding at six months, care providers should ensure accessible infant feeding support is available to all new mothers., (Copyright © 2020 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: In Australia, it is estimated that 9.5% of women of childbearing age have a disability; however, little is known about their perinatal outcomes. Disability status is not routinely recorded in perinatal datasets., Aims: To compare the outcomes of women with a disability who received pregnancy care through a specialised disability clinic at the Royal Women's Hospital (the Women's) in Melbourne, Australia with hospital-wide perinatal outcome data., Materials and Methods: Routinely collected perinatal data for women who received pregnancy care from the 'Women with Individual Needs' (WIN) clinic from 2014-2018 (N = 111) were analysed and then compared with routinely collected electronic hospital data obtained from all women who had given birth at the Women's in 2017 and 2018 (N = 15 024)., Results: Women who attended the WIN clinic were more likely to have a caesarean section birth (52% vs 32%; P < 0.001) and give birth preterm (17% vs 4%; P < 0.001) than those in the hospital-wide cohort. Their infants were more likely to be low birthweight (20% vs 9%; P < 0.001), require resuscitation (35% vs 11%; P < 0.001), be admitted to the Neonatal Intensive Special Care Unit (29% vs 13%; P < 0.001) and receive formula in hospital (54% vs 28%; P < 0.001) compared to infants in the other group., Conclusions: Routine maternity data collection should include identification of women with a disability to enable appropriate support and to allow further exploration of potential poorer outcomes on a larger sample, to help identify factors amenable to interventions that may improve outcomes., (© 2021 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Objective: The Ringing Up about Breastfeeding earlY (RUBY) randomised controlled trial (RCT) of proactive telephone-based peer support for breastfeeding found that infants of women allocated to the intervention were more likely to be receiving breast milk at 6 months of age than those receiving usual care. This study explores women's experiences of receiving the RUBY peer support intervention., Design: Cross-sectional survey., Setting: Women were recruited from the postnatal units of three tertiary hospitals in Melbourne, Australia., Participants: Women allocated to receive telephone peer support in the RUBY RCT who completed a telephone interview at 6 months postpartum (501/574 (87%) in trial intervention arm) were invited to complete a postal survey on their experience of receiving support., Outcomes: Experiences of support from the allocated peer, perceived helpfulness, topics discussed, overall satisfaction with the support and frequency and duration of contact were explored., Results: Surveys were sent between August 2013 and March 2016, and 72% (360/501) responded of whom 341 recalled receiving peer support. Women reported high levels of perceived helpfulness (79%) and overall satisfaction with the peer support (93%). Discussions included breastfeeding topics (milk supply, attachment), baby care, baby behaviour, and reassurance and emotional support. Women valued the practical and realistic support from another mother, as well as the proactive nature, continuity and accessibility of the support. The empathy, reassurance and encouragement provided helped the mothers to 'cope', to continue breast feeding and to feel empowered., Conclusion: Most respondents were positive about their experience of receiving proactive telephone peer support for breastfeeding, further supporting the roll-out of this model as a strategy for increasing breastfeeding maintenance to 6 months. Recommendations include flexibility in the scheduling of calls according to individual need, and the use of text messages in conjunction with proactive calls, to enhance and facilitate communication between the peer and the mother., Trial Registration Number: ACTRN12612001024831., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: There is growing evidence that peer support programs may be effective in supporting breastfeeding mothers. A randomised controlled trial (RCT) (the RUBY study) that tested peer support in the Australian context found that infants of first-time mothers who received proactive telephone peer support were more likely to be receiving breastmilk at six months of age., Methods: This qualitative sub-study of the RUBY RCT explores the experiences and views of peer volunteers who delivered the intervention. Focus groups were conducted with 17 peers from the RUBY RCT between November 2015 and March 2016. All had provided peer support to at least one mother., Results: We found that volunteers identified strongly with the mothers' need for support when establishing breastfeeding. Key components of the support were strengthening the mothers' self-belief through affirmation and sharing experiential knowledge. Volunteers found the role rewarding and personally therapeutic although some women reported challenges initiating and maintaining contact with some mothers. Data were analysed using a hybrid approach to thematic analysis combining inductive and deductive techniques., Conclusions: Breastfeeding peer support programs are reliant on recruitment of motivated volunteers who can provide empathetic mother-to-mother support. This study provides important information regarding volunteers' experiences that may support the upscaling of breastfeeding peer support for new mothers., Trial Registration: Australian New Zealand Clinical Trials Registry, ACTRN 12612001024831., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Over 310 000 women gave birth in Australia in 2016, with approximately 80 000 births in the state of Victoria. While most of these births occur in metropolitan Melbourne and other large regional centres, a significant proportion of Victorian women birth in local rural health services. The Victorian state government recently mandated the provision of a maternal and neonatal emergency training programme, called Maternal and Newborn Emergencies (MANE), to rural and regional maternity service providers across the state. MANE aims to educate maternity and newborn care clinicians about recognising and responding to clinical deterioration in an effort to improve clinical outcomes. This paper describes the protocol for an evaluation of the MANE programme., Methods and Analysis: This study will evaluate the effectiveness of MANE in relation to: clinician confidence, skills and knowledge; changes in teamwork and collaboration; and consumer experience and satisfaction, and will explore and describe any governance changes within the organisations after MANE implementation. The Kirkpatrick Evaluation Model will provide a framework for the evaluation. The participants of MANE, 27 rural and regional Victorian health services ranging in size from approximately 20 to 1000 births per year, will be invited to participate. Baseline data will be collected from maternity service staff and consumers at each health service before MANE delivery, and at four time-points post-MANE delivery. There will be four components to data collection: a survey of maternity services staff; follow-up interviews with Maternity Managers at health services 4 months after MANE delivery; consumer feedback from all health services collected through the Victorian Healthcare Experience Survey; case studies with five regional or rural health service providers., Ethics and Dissemination: This evaluation has been approved by the La Trobe University Science, Health and Engineering College Human Ethics Sub-Committee. Findings will be presented to project stakeholders in a deidentified report, and disseminated through peer-reviewed publications and conference presentations., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To compare perinatal and maternal outcomes for Australian women with uncomplicated pregnancies according to planned place of birth, that is, in hospital labour wards, birth centres or at home., Design: A population-based retrospective design, linking and analysing routinely collected electronic data. Analysis comprised χ 2 tests and binary logistic regression for categorical data, yielding adjusted ORs. Continuous data were analysed using analysis of variance., Setting: All eight Australian states and territories., Participants: Women with uncomplicated pregnancies who gave birth between 2000 and 2012 to a singleton baby in cephalic presentation at between 37 and 41 completed weeks' gestation. Of the 1 251 420 births, 1 171 703 (93.6%) were planned in hospital labour wards, 71 505 (5.7%) in birth centres and 8212 (0.7%) at home., Main Outcome Measures: Mode of birth, normal labour and birth, interventions and procedures during labour and birth, maternal complications, admission to special care/high dependency or intensive care units (mother or infant) and perinatal mortality (intrapartum stillbirth and neonatal death)., Results: Compared with planned hospital births, the odds of normal labour and birth were over twice as high in planned birth centre births (adjusted OR (AOR) 2.72; 99% CI 2.63 to 2.81) and nearly six times as high in planned home births (AOR 5.91; 99% CI 5.15 to 6.78). There were no statistically significant differences in the proportion of intrapartum stillbirths, early or late neonatal deaths between the three planned places of birth., Conclusions: This is the first Australia-wide study to examine outcomes by planned place of birth. For healthy women in Australia having an uncomplicated pregnancy, planned births in birth centres or at home are associated with positive maternal outcomes although the number of homebirths was small overall. There were no significant differences in the perinatal mortality rate, although the absolute numbers of deaths were very small and therefore firm conclusions cannot be drawn about perinatal mortality outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Significant gaps exist in education for prospective and new parents, especially for some of the most vulnerable families. Prospective parents would like more information during pregnancy to prepare them for parenting, and need access to trusted and quality information. The Royal Women's Hospital (the Women's) in Melbourne, Australia, a large tertiary referral maternity hospital, developed a parenting education kit known as 'Growing Together'. The kit, designed to guide prospective and new parents from conception until 1 year after birth, includes three components: an A4 sized book, a specifically designed 'App' and a children's story book. We aim to evaluate the impact of the kit on a range of outcomes., Methods: A two-arm cluster randomised controlled trial will be used. Antenatal clinic days will be randomised to either the intervention or standard care arms. Women in the intervention arm receive the kit at their antenatal booking visit. Women in the standard care arm receive the standard information resources at the Women's. Analyses will be by intention to treat., Inclusion Criteria: primiparous women with adequate English-speaking ability and ≤ 30 weeks' gestation at first pregnancy booking appointment. The primary outcome of the study is the 'experience of motherhood questionnaire' (EMQ), a 20 item validated self-report measure, ranging from 0 to 80, with lower scores indicating better maternal health and wellbeing. To detect a 10% difference in new mothers scoring ≤40 between women who have received the kit (60%) and those who have not (50%), would require 408 per group (total of 816 women) with 95% confidence and 80% power. Allowing for loss to follow up, we aim to recruit 1000 mothers. Secondary outcomes include parents' views and experiences of their care and of the kit during pregnancy and after the birth, parental attachment, knowledge, confidence, wellbeing and health-seeking behaviour; and emotional, developmental and physical health of the infant. Survey data will be collected from mothers at 2, 6 and 12 months postpartum and partners at 6 months., Discussion: This study will provide much needed high-level evidence on the impact of a comprehensive education resource for new parents., Trial Registration: ANZCTRN12615000270516 - Retrospectively registered (23/03/2015); trial started on 16 March 2015.

Perinatal mental health is an important public health issue, and peer support is a potentially important strategy for emotional well-being in the perinatal period. PANDA Perinatal Anxiety & Depression Australia provides support to individuals impacted by perinatal mental health issues via the National Perinatal Anxiety & Depression Helpline. Callers receive peer support from volunteers and counselling from paid professional staff. The views and experiences of PANDA peer support volunteers have not previously been studied. We conducted two focus groups and an online survey to explore the experiences of women providing volunteer peer support on the Helpline. Data collection took place in October and November 2013. Two social theories were used in framing and addressing the study aims and in interpreting our findings: the Empathy-Altruism Hypothesis, and the Helper Therapy Principle. All PANDA volunteers were invited to participate (n = 40). Eight volunteers attended a focus group, and 11 survey responses were received. Descriptive statistics were used to analyse quantitative data. All survey respondents 'strongly agreed' that they felt positive about being part of PANDA. Thematic analysis of data from focus groups and open-ended survey responses identified the following themes: motivated to help others, supported to support callers, helping to make a difference and emotional impacts for volunteers. Respondents described a strong desire to support others experiencing emotional distress as a motivator to volunteer. Although perinatal peer support services are designed to benefit those who receive support, this study suggests volunteers may also experience personal benefits from the role., (© The Author(s) 2018. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: It is critical women's voices are heard if there is to be more widespread implementation of midwifery-led continuity models. Publicly-funded homebirth is one such model, yet there has been limited systematic evaluation from the women's perspective., Aim: Examine women's experiences of and views about the two publicly-funded homebirth programs in Victoria, Australia., Methods: A cross-sectional design was used. All eligible women enrolled in the two pilot homebirth programs in metropolitan Melbourne whose infants were eight weeks of age or more during the evaluation period were invited to participate in a postal survey. A structured questionnaire was used, with some open-ended questions to enable extra comments. We explored women's reasons for choosing homebirth; views of care; experience of labour and birth; views on transfer; and overall experience of the homebirth program. Data were analysed using descriptive statistics. Simple thematic analysis was used for open-ended questions., Findings: The survey response rate was 71% (96/136). A high percentage of women rated their care as 'Very good': pregnancy 81%; labour and birth 90%; and the early postpartum period 83%. Women reported low levels of anxiety during labour and birth, were able to express their feelings, felt in control, and coped physically and emotionally better than they had expected. They felt well supported by midwives and overall reported very positive experiences of the homebirth programs., Conclusions: These two publicly-funded homebirth pilot programs demonstrated very positive care ratings by women. These findings, along with the clinical outcomes (reported separately), support the continuation and expansion of the program., (Copyright © 2018 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

In Australia, the PANDA-Perinatal Anxiety & Depression Australia National Helpline (the Helpline) offers support to callers impacted by emotional health challenges in the perinatal period. Callers receive counselling from professional staff and peer support from volunteers. An understanding of factors that contribute to callers' experiences of emotional distress, as well as potential barriers and facilitators to help-seeking, can be used to inform future service design and delivery. A caller intake form is completed by Helpline staff when an individual contacts the service for the first time, or re-engages after a period of non-contact. We analysed all intake forms of individuals calling about their own emotional wellbeing from the middle month of each season in 2014: January, April, July, and October. Content analysis was undertaken, focusing on caller profile, patterns of help-seeking, and reasons for caller engagement. Of the 365 calls, the majority were from women (n = 358, 98%) who were pregnant (n = 59, 16%) or had a child ≤12 months of age (n = 241, 75%). Many were seeking support regarding depression (n = 186, 51%) or anxiety (n = 162, 44%), with a number seeking help for both (n = 71, 20%). Almost a third were identified as being 'at risk', including a number who were experiencing thoughts of suicide or self-harm. Complex interrelating factors contributed to callers' emotional distress, including: stressful life events; pregnancy, birthing and parenting experiences; social isolation; and histories of mental health difficulties. Significant numbers of parents experience emotional health challenges in the perinatal period, but many do not receive adequate treatment. Complex factors contribute to callers' distress, highlighting the need for health professionals to undertake thorough psychosocial assessments during the perinatal period so those that need additional support are identified, and appropriate care provided. Telephone Helplines like PANDAs assist overcoming barriers to care and provide specialised perinatal mental health support to families., (© 2018 John Wiley & Sons Ltd.)

Background: Breastfeeding rates are suboptimal internationally, and many infants are not receiving any breast milk at all by six months of age. Few interventions increase breastfeeding duration, particularly where there is relatively high initiation. The effect of proactive peer (mother-to-mother) support has been found to increase breastfeeding in some contexts but not others, but if it is shown to be effective would be a potentially sustainable model in many settings. We aimed to determine whether proactive telephone-based peer support during the postnatal period increases the proportion of infants being breastfed at six months of age., Methods: RUBY (Ringing Up about Breastfeeding earlY) was a multicentre, two-arm un-blinded randomised controlled trial conducted in three hospitals in Victoria, Australia. First-time mothers intending to breastfeed were recruited after birth and prior to hospital discharge, and randomly assigned (1:1) to usual care or usual care plus proactive telephone-based breastfeeding support from a trained peer volunteer for up to six months postpartum. A computerised random number program generated block sizes of four or six distributed randomly, with stratification by site. Research midwives were masked to block size, but masking of allocation was not possible. The primary outcome was the proportion of infants receiving any breast milk at six months of age. Analyses were by intention to treat; data were collected and analysed masked to group. The trial is registered with ACTRN, number 12612001024831., Findings: Women were recruited between Feb 14, 2013 and Dec 15, 2015 and randomly assigned to peer support ( n  = 574) or usual care ( n  = 578). Five were not in the primary analysis [5 post-randomisation exclusions]. Infants of women allocated to telephone-based peer support were more likely than those allocated to usual care to be receiving breast milk at six months of age (intervention 75%, usual care 69%; Adj. RR 1·10; 95% CI 1·02, 1·18). There were no adverse events., Interpretation: Providing first time mothers with telephone-based support from a peer with at least six months personal breastfeeding experience is an effective intervention for increasing breastfeeding maintenance in settings with high breastfeeding initiation., Funding: The Felton Bequest, Australia, philanthropic donation and La Trobe University grant.

The PANDA Perinatal Anxiety & Depression Australia National Helpline provides support for people affected by perinatal mental health issues. To describe the characteristics of women contacting the Helpline, specifically callers' health, past history and assessed risk factors. Analysis of routinely collected de-identified data of women making initial calls between July 2010 and October 2013. Five thousand eight hundred eighteen women made an initial call to the Helpline. Most were between 25 and 40 years old (79%) and married/partnered (94%); 52% were having or had their first child; and 23% were pregnant. Over half had no prior mental health diagnosis at the time of their initial call, and 40% were assessed as 'high needs'-experiencing significant bio-psychosocial symptoms, complex situations and/or inadequate care and support. There was a 70% increase in calls to PANDA over the data collection period. Concerns recorded by PANDA staff from the initial risk assessment included inadequate treatment for a mental health condition (31%), women not feeling connected to their baby (31%), low functioning (26%) and general thoughts of suicide (18%). The Helpline experienced a significant increase in demand during the study period, and a substantial proportion of callers had complex mental health needs. PANDA plays a major role in providing support to a large number of women experiencing perinatal mental health problems.

Background: Despite high-level evidence of the benefits of caseload midwifery for women and babies, little is known about specific practice arrangements, organisational barriers and facilitators, nor about workforce requirements of caseload. This paper explores how caseload models across Australia operate., Methods: A national cross-sectional, online survey of maternity managers in public maternity hospitals with birthing services was undertaken. Only services with a caseload model are included in the analysis., Findings: Of 253 eligible hospitals, 149 (63%) responded, of whom 44 (31%) had a caseload model. Operationalisation of caseload varied across the country. Most commonly, caseload midwives were required to work more than 0.5 EFT, have more than one year of experience and have the skills across the whole scope of practice. On average, midwives took a caseload of 35-40 women when full time, with reduced caseloads if caring for women at higher risk. Leave coverage was complex and often ad-hoc. Duration of home-based postnatal care varied and most commonly provided to six weeks. Women's access to caseload care was impacted by many factors with geographical location and obstetric risk being most common., Conclusion: Introducing, managing and operationalising caseload midwifery care is complex. Factors which may affect the expansion and availability of the model are multi-faceted and include staffing and model inclusion guidelines. Coverage of leave is a factor which appears particularly challenging and needs more focus., (Copyright © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: While Australia has high breastfeeding initiation, there is a sharp decline in the first weeks postpartum and this continues throughout the first year. Supporting breastfeeding In Local Communities (SILC) was a three-arm cluster randomised controlled trial to determine whether early home-based breastfeeding support by a maternal and child health nurse (SILC-MCHN), with or without access to a community-based breastfeeding drop-in centre, increased the proportion of infants receiving any breast milk at three, four and six months. The trial was conducted in ten Local Government Areas (LGAs) in Victoria, Australia.The primary aim of this paper is to describe the three drop-in centres established during the trial; and the profile of women who accessed them. The secondary aim is to explore the views and experiences of the drop-in centre staff, and the challenges faced in establishing and maintaining a breastfeeding drop-in centre in the community., Methods: Evaluation of the three LGAs with drop-in centres was multifaceted and included observational visits and field notes; data collected from attendance log books from each drop-in centre; a written survey and focus groups with maternal and child health (MCH) nurses who ran the drop-in centres; and semi-structured interviews with MCH coordinators of the participating LGAs., Results: The three LGAs developed and ran different models of breastfeeding drop-in centres. They reported challenges in finding convenient, accessible locations. Overall, attendance was lower than expected, with an average of only one attendee per session. Two global themes were identified regarding staff views: implementation challenges , encompassing finding accessible, available space, recruiting volunteers to provide peer support, and frustration when women did not attend; and the work of SILC-MCHNs , including themes of satisfying and rewarding work, juggling roles, and benefits to women, babies and the community., Conclusion: Providing community-based breastfeeding support was satisfying for the drop-in centre staff but proved difficult to implement, reflected by the lower than anticipated attendances at all of the drop-in centres. Interventions to increase breastfeeding in complex community settings require sufficient time to build partnerships with the existing services and the target population; to understand when and how to offer interventions for optimum benefit., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12611000898954.

Background: Increasing breastfeeding rates is one way of improving the short and long term health of Aboriginal and Torres Strait Islander children (hereafter referred to as Aboriginal). Despite the benefits of breastfeeding and recommendations for strategies to increase breastfeeding among Aboriginal people, there is a lack of available population data., Aim: To use population-based data from Victoria, Australia to compare breastfeeding initiation for Aboriginal and non-Aboriginal women and to explore factors associated with breastfeeding initiation of Aboriginal women., Methods: Routinely collected infant feeding data obtained from the Victorian Perinatal Data Collection (VPDC) was used. The VPDC is a mandatory, population-based system where maternal and infant data on all Victorian births are collected., Findings: Compared with non-Aboriginal women, Aboriginal women were less likely to attempt to breastfeed their baby (87.2% vs 95.3%; p<0.001); more likely to give formula in hospital (39.6% vs 30.6%; p<0.001) and less likely to give the last feed prior to discharge exclusively from the breast (64.4% vs 75.0% p<0.001). For Aboriginal women, factors associated with not initiating breastfeeding were being single, multiparous, smoking and length of stay. Infant factors were gestation less than 37 weeks and low birthweight (<2,500g)., Conclusion: In Victoria, breastfeeding initiation is lower for Aboriginal women compared with non-Aboriginal women. Further research is needed to explore the effectiveness of interventions that may increase breastfeeding for Aboriginal women., (Copyright © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: The Supporting breastfeeding In Local Communities (SILC) cluster randomized controlled trial evaluated whether a home visit focussed on infant feeding early in the postpartum period increased the percentage of infants breastfeeding at 4 months in low socioeconomic areas of Victoria, Australia. The visits were offered to women identified as at risk of early breastfeeding cessation after discharge home with a new baby. This paper describes the content of the home visits., Methods: SILC visited 1,043 women from September 2012 to March 2013, and completed a data sheet for each visit documenting topics discussed, as well as what support and resources were offered. Frequencies and percentages are presented., Results: Home visits most commonly included the provision of reassurance to women (91%). Topics discussed included general breastfeeding information (83%), supply and demand (83%), positioning (79%), and feeding frequency (78%). Newborn feeding/behavior (57%), expression of breastmilk (54%), nipple pain (41%), low breastmilk supply (41%), and the use of nipple shields (18%) were also prominent topics. The issues and support needs of women were similar across locations (rural, regional or metropolitan) and regardless of maternal parity or age. There was some variation in the resources suggested in different localities., Conclusions: New mothers require help and reassurance independent of whether this is their first or subsequent child, reinforcing the need for support, breastfeeding information, and education about normal neonatal behavior. Key aspects of support are reassurance, normalization of infant behavior, and education., (© 2016 Wiley Periodicals, Inc.)

Background: Caseload midwifery models are becoming more common in Australian maternity care. Little is known about how caseload midwifery compares with mainstream models of midwifery care in terms of both the organisation of the work and the meaning of the work for caseload midwives., Aim: To explore caseload and standard care midwives' views and experiences of midwifery work in two new caseload models in Victoria, Australia., Methods: A mixed-methods approach was used. Quantitative data were collected using two cross-sectional surveys of midwives at the two study sites at the commencement of the caseload model and after two years. Qualitative data were collected using in-depth interviews with caseload midwives six months and two years after commencing in the role. Content analysis was used to analyse open-ended survey questions, and interview data were analysed thematically. Themes arising from these data sources were then considered using Normalization Process Theory., Findings: Two themes emerged from the data. Caseload midwifery was a 'different' way of working, involving activity-based work, working on-call, fluid navigation between work and personal time and avoiding burnout. Working in caseload was also perceived by caseload midwives to be 'real' midwifery, facilitating relationships with women, and requiring responsibility, accountability, autonomy and legitimacy in their practice. Perceptions of caseload work were influenced by understanding these differences in caseload work compared to mainstream maternity care., Conclusion: Increased understanding of the differences between caseload work and mainstream maternity models, and introducing opportunities to be exposed to caseload work may contribute to sustainability of caseload models., (Copyright © 2015 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: There is limited evidence regarding the provision of home-based postnatal care, resulting in a weak evidence-base for policy formulation and the further development of home-based postnatal care services., Aim: To explore the structure and organisation of public hospital home-based postnatal care in Victoria, Australia., Methods: An online survey including mostly closed-ended questions was sent to representatives of all public maternity providers in July 2011., Findings: The response rate of 87% (67/77) included rural (70%; n=47), regional (15%; n=10) and metropolitan (15%; n=10) services. The majority (96%, 64/67) provided home-based postnatal care. The median number of visits for primiparous women was two and for multiparous women, one. The main reason for no visit was the woman declining. Two-thirds of services attempted to provide some continuity of carer for home-based postnatal care. Routine maternal and infant observations were broadly consistent across the services, and various systems were in place to protect the safety of staff members during home visits. Few services had a dedicated home-based postnatal care coordinator., Discussion and Conclusion: This study demonstrates that the majority of women receive at least one home-based postnatal visit, and that service provision on the whole is similar across the state. Further work should explore the optimum number and timing of visits, what components of care are most valued by women, and what model best ensures the timely detection and prevention of postpartum complications, be they psychological or physiological., (Copyright © 2015 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Continuity of care by a primary midwife during the antenatal, intrapartum and postpartum periods has been recommended in Australia and many hospitals have introduced a caseload midwifery model of care. The aim of this paper is to evaluate the effect of caseload midwifery on women's satisfaction with care across the maternity continuum., Methods: Pregnant women at low risk of complications, booking for care at a tertiary hospital in Melbourne, Australia, were recruited to a randomised controlled trial between September 2007 and June 2010. Women were randomised to caseload midwifery or standard care. The caseload model included antenatal, intrapartum and postpartum care from a primary midwife with back-up provided by another known midwife when necessary. Women allocated to standard care received midwife-led care with varying levels of continuity, junior obstetric care, or community-based general practitioner care. Data for this paper were collected by background questionnaire prior to randomisation and a follow-up questionnaire sent at two months postpartum. The primary analysis was by intention to treat. A secondary analysis explored the effect of intrapartum continuity of carer on overall satisfaction rating., Results: Two thousand, three hundred fourteen women were randomised: 1,156 to caseload care and 1,158 to standard care. The response rate to the two month survey was 88% in the caseload group and 74% in the standard care group. Compared with standard care, caseload care was associated with higher overall ratings of satisfaction with antenatal care (OR 3.35; 95% CI 2.79, 4.03), intrapartum care (OR 2.14; 95% CI 1.78, 2.57), hospital postpartum care (OR 1.56, 95% CI 1.32, 1.85) and home-based postpartum care (OR 3.19; 95% CI 2.64, 3.85)., Conclusion: For women at low risk of medical complications, caseload midwifery increases women's satisfaction with antenatal, intrapartum and postpartum care., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN012607000073404 (registration complete 23rd January 2007).

Objectives: Breastfeeding has significant health benefits for mothers and infants. Despite recommendations from the WHO, by 6 months of age 40% of Australian infants are receiving no breast milk. Increased early postpartum breastfeeding support may improve breastfeeding maintenance. 2 community-based interventions to increase breastfeeding duration in local government areas (LGAs) in Victoria, Australia, were implemented and evaluated., Design: 3-arm cluster randomised trial., Setting: LGAs in Victoria, Australia., Participants: LGAs across Victoria with breastfeeding initiation rates below the state average and > 450 births/year were eligible for inclusion. The LGA was the unit of randomisation, and maternal and child health centres in the LGAs comprised the clusters., Interventions: Early home-based breastfeeding support by a maternal and child health nurse (home visit, HV) with or without access to a community-based breastfeeding drop-in centre (HV+drop-in)., Main Outcome Measures: The proportion of infants receiving 'any' breast milk at 3, 4 and 6 months (women's self-report)., Findings: 4 LGAs were randomised to the comparison arm and provided usual care (n=41 clusters; n=2414 women); 3 to HV (n=32 clusters; n=2281 women); and 3 to HV+drop-in (n=26 clusters; 2344 women). There was no difference in breastfeeding at 4 months in either HV (adjusted OR 1.04; 95% CI 0.84 to 1.29) or HV+drop-in (adjusted OR 0.92; 95% CI 0.78 to 1.08) compared with the comparison arm, no difference at 3 or 6 months, nor in any LGA in breastfeeding before and after the intervention. Some issues were experienced with intervention protocol fidelity., Conclusions: Early home-based and community-based support proved difficult to implement. Interventions to increase breastfeeding in complex community settings require sufficient time and partnership building for successful implementation. We cannot conclude that additional community-based support is ineffective in improving breastfeeding maintenance given the level of adherence to the planned protocol., Trial Registration Number: ACTRN12611000898954; Results., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objective: this paper describes the use of breast pumps amongst a group of mothers of healthy term infants in Melbourne, Australia, between birth and six months post partum., Design: a prospective cohort study; data were collected using structured questionnaires., Participants: 1003 postpartum women who had given birth to healthy infants at term were recruited from three Melbourne maternity hospitals between July 2009 and April 2011. Data were collected by face-to-face interview at recruitment and by telephone interview three and six months later., Findings: at recruitment (24 to 48 hours post partum), 60% (605/1003) of women already had a breast pump. At two weeks post partum expressing was common; 62% (290/466) of women had expressed by this time, with 40% (186/466) doing so several times a day. By six months post partum 83% (754/911) of the women had a breast pump and 40% (288/715) were expressing, although most just occasionally. The most common reasons for any expressing in the first six months were 'to be able to go out and leave the baby' (35%; 268/772); milk supply 'not enough'(27%; 207/772); and having 'too much' milk (19%; 147/772). The increasing popularity of expressing breast milk to feed infants is not driven by women returning to the workforce, as only 10% of women (80/772) expressed because they had returned to paid employment., Key Conclusions and Implications for Practice: health professionals should be aware that in some settings breast pump use is common in the first six months, and this is not always related to maternal workforce participation., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Anxiety and depression are common in the perinatal period. Telephone interventions, including telephone peer support and counselling, have been developed to support those experiencing perinatal mental illness. PANDA Post and Antenatal Depression Association provides support to women and men experiencing perinatal mental illness via the Australian National Perinatal Depression Helpline, encompassing both volunteer peer support and professional counselling. This study aimed to explore the experiences of callers to the Helpline., Methods: A cross-sectional survey design was used. All new callers from 1(st) May to 30(th) September 2013 were invited to participate. The survey, adapted from a previous survey of PANDA callers, included 23 questions using Likert-type scales, demographic and open-ended questions. Thematic network analysis was undertaken for responses to open-ended questions., Results: 124 responses were received (124/405; 30% response). The majority of callers had called the Helpline regarding themselves (90%), with over one third (33%) of all callers seeking crisis support and help. Ninety-nine per cent of respondents 'agreed' or 'strongly agreed' that staff and/or volunteers understood their concerns, and 97% 'agreed' or 'strongly agreed' that overall PANDA had helped them. Callers described the PANDA service as uniquely tailored to the perinatal period, providing accessible, non-judgemental understanding and support, with a global theme from open-ended comments describing PANDA as 'a safe space to be heard and receive support without judgement'. Recommendations for service changes included increased hours of availability., Conclusions: Callers reported positive experiences of accessing support from the PANDA National Perinatal Depression Helpline. The Helpline was described as an accessible and acceptable telephone support for individuals experiencing perinatal mental illness. Recommendations for changes to the service included an increase in hours of operation to enable greater responsiveness at times of need, reduced waiting times, and access to continuity with the same volunteer and/or telephone counsellor. The findings of the study will be useful in informing future service provision, review, and implementation.

Objective: To explore whether feeding only directly from the breast in the first 24-48 h of life increases the proportion of infants receiving any breast milk at 6 months., Design: A prospective cohort study., Setting: Three maternity hospitals in Melbourne, Australia., Participants: 1003 postpartum English-speaking women with a healthy singleton term infant, who intended to breast feed, were recruited between 2009 and 2011. Women were excluded if they or their infant were seriously ill. 92% (n=924) were followed up at 6 months postpartum., Primary and Secondary Outcome Measures: Main exposure variable - type of infant feeding in hospital up to time of study recruitment (24-48 h postpartum), categorised as 'fed directly at the breast only' or 'received at least some expressed breast milk (EBM) or infant formula'. Primary outcome - proportion of infants receiving any breast milk feeding at 6 months postpartum. Secondary outcomes - proportion of infants receiving only breast milk feeding at 6 months; breast milk feeding duration; and maternal characteristics associated with giving any breast milk at 6 months., Results: Infants who had fed only at the breast prior to recruitment were more likely to be continuing to have any breast milk at 6 months than those who had received any EBM and/or infant formula (76% vs 59%; adjusted OR 1.76, 95% CI 1.24 to 2.48 (adjusted for parity, type of birth, breastfeeding intention, breastfeeding problems at recruitment, public/private status, epidural for labour or birth, maternal body mass index and education))., Conclusions: Healthy term infants that fed only directly at the breast 24-48 h after birth were more likely to be continuing to breast feed at 6 months than those who received any EBM and/or formula in the early postpartum period. Support and encouragement to initiate breastfeeding directly at the breast is important., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Caseload midwifery reduces childbirth interventions and increases women's satisfaction with care. It is therefore important to understand the impact of caseload midwifery on midwives working in and alongside the model. While some studies have reported higher satisfaction for caseload compared with standard care midwives, others have suggested a need to explore midwives' work-life balance as well as potential for stress and burnout. This study explored midwives' attitudes to their professional role, and also measured burnout in caseload midwives compared to standard care midwives at two sites in Victoria, Australia with newly introduced caseload midwifery models., Methods: All midwives providing maternity care at the study sites were sent questionnaires at the commencement of the caseload midwifery model and two years later. Data items included the Midwifery Process Questionnaire (MPQ) to examine midwives' attitude to their professional role, the Copenhagen Burnout Inventory (CBI) to measure burnout, and questions about midwives' views of caseload work. Data were pooled for the two sites and comparisons made between caseload and standard care midwives. The MPQ and CBI data were summarised as individual and group means., Results: Twenty caseload midwives (88%) and 130 standard care midwives (41%) responded at baseline and 22 caseload midwives (95%) and 133 standard care midwives (45%) at two years. Caseload and standard care midwives were initially similar across all measures except client-related burnout, which was lower for caseload midwives (12.3 vs 22.4, p = 0.02). After two years, compared to midwives in standard care, caseload midwives had higher mean scores in professional satisfaction (1.08 vs 0.76, p = 0.01), professional support (1.06 vs 0.11, p <0.01) and client interaction (1.4 vs 0.09, p <0.01) and lower scores for personal burnout (35.7 vs 47.7, p < 0.01), work-related burnout (27.3 vs 42.7, p <0.01), and client-related burnout (11.3 vs 21.4, p < 0.01)., Conclusion: Caseload midwifery was associated with lower burnout scores and higher professional satisfaction. Further research should focus on understanding the key features of the caseload model that are related to these outcomes to help build a picture of what is required to ensure the long-term sustainability of the model.

Background: Postnatal care in hospital is often provided using defined care pathways, with limited opportunity for more refined and individualised care. We explored whether a tertiary maternity service could provide flexible, individualised early postnatal care for women in a dynamic and timely manner, and if this approach was acceptable to women., Methods: A feasibility study was designed to inform a future randomised controlled trial to evaluate an alternative approach to postnatal care. English-speaking women at low risk of medical complications were recruited around 26 weeks gestation to explore their willingness to participate in a study of a new, flexible model of care that involved antenatal planning for early postpartum discharge with additional home-based postnatal care. The earlier women were discharged from hospital, the more home-based visits they were eligible to receive. Program uptake was measured, women's views obtained by a postal survey sent at eight weeks postpartum and clinical data collected from medical records., Results: Study uptake was 39% (109/277 approached). Most women (n=103) completed a postnatal care plan during pregnancy; 17% planned to leave hospital within 12 hours of giving birth and 36% planned to stay 48 hours. At eight weeks postpartum most women (90%) were positive about the concept and 88% would opt for the same program again. Of the 28% who stayed in hospital for the length they had planned, less than half (43%) received the appropriate number of home visits, and only 41% were given an option for the timing of the visit. Most (62%) stayed in hospital longer than planned (probably due to clinical complications); 11% stayed shorter than planned., Conclusions: Women were very positive about individualised postnatal care planning that commenced during pregnancy. Given the hospital stay may be impacted by clinical factors, individualised care planning needs to continue into the postnatal period to take into account circumstances which cannot be planned for during pregnancy. However, individualised care planning during the postnatal period which incorporates a high level of flexibility may be challenging for organisations to manage and implement, and a randomised controlled trial of such an approach may not be feasible.

Background: Breastfeeding is associated with significant positive health outcomes for mothers and infants. However, despite recommendations from the World Health Organization, exclusive breastfeeding for six months is uncommon. Increased breastfeeding support early in the postpartum period may be effective in improving breastfeeding maintenance. This trial will evaluate two community-based interventions to increase breastfeeding duration in Local Government Areas (LGAs) in Victoria, Australia., Methods/design: A three-arm cluster randomised controlled trial design will be used. Victorian LGAs with a lower than average rate of any breastfeeding at discharge from hospital and more than 450 births per year that agree to participate will be randomly allocated to one of three trial arms: 1) standard care; 2) home-based breastfeeding support; or 3) home-based breastfeeding support plus access to a community-based breastfeeding drop-in centre. The services provided in LGAs allocated to 'standard care' are those routinely available to postpartum women. LGAs allocated to the home-based visiting intervention will provide home-visits to women who are identified as at risk of breastfeeding cessation in the early postnatal period. These visits will be provided by Maternal and Child Health Nurses who have received training to provide the intervention (SILC-MCHNs). In areas allocated to receive the second intervention, in addition to home-based breastfeeding support, community breastfeeding drop-in centres will be made available, staffed by a SILC-MCHN. The interventions will run in LGAs for a nine to twelve month period depending on birth numbers. The primary outcome is the proportion of infants receiving any breast milk at four months of age. Breastfeeding outcomes will be obtained from routinely collected Maternal and Child Health centre data and from a new data item collecting infant feeding 'in the last 24 hours'. Information will also be obtained directly from women via a postal survey. A comprehensive process evaluation will be conducted., Discussion: This study will determine if early home-based breastfeeding support by a health professional for women at risk of stopping breastfeeding, with or without access to a community-based breastfeeding drop-in centre, increases breastfeeding duration in Victorian LGAs with low breastfeeding rates., Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN12611000898954.