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Aim. This paper draws on theory and evidence to develop a conceptual staff training model for the management of 'challenging behaviour'. Background. Staff working with clients who are experienced as challenging commonly report negative feelings such as anxiety, anger, guilt, fear, self-blame and powerlessness, as well as dissatisfaction with their jobs. Current training programmes in challenging behaviour offer a 'smorgasbord' of content, without a clearly defined conceptual framework. Data sources. Medline and PsychInfo were searched for papers in English from 1998 to 2008, linking 'nurs*' to 'challenging behavio*' and its related terms. Additional hand-searching identified informative papers from disciplines outside nursing older than the search period. Discussion. We developed an applied model for training educators in respect of challenging behaviours. The model directs educators to consider: the influence of the nurse, including their values, emotional processes and behavioural skills; features of the client; and features of the situation in which the behaviour occurs, including its culture and working practices and physical environment. Implications for nursing. The most striking implication of the model is that it explicitly recognizes the importance of domains of learning other than skill. This enables educators to find educationally appropriate responses to resource limitations that inevitably constrain training. Conclusion. Challenging behaviour should be considered as a product of several intertwined factors: the actors involved -- nurses, clients and others -- and the situation in which the behaviour occurs, including its culture and working practices and physical environment. [ABSTRACT FROM AUTHOR]

Purpose: Rural women and their babies experience poorer perinatal outcomes than their urban counterparts and this inequity has existed for decades. This study explored the barriers and enablers that exist for rural women in Australia in accessing perinatal care., Methods: A qualitative descriptive design, using reflexive thematic analysis, was employed. Semi-structured interviews were conducted in 2023 with women who had recently given birth in rural Victoria, Australia (n=19). A purposive sampling strategy was used, recruiting women via social media platforms from rural communities across the state. The Socioecological Model (SEM) was used as a framework to organise the findings., Results: Study participants reported multilevel barriers and enablers to accessing perinatal care in their own communities. Intrapersonal factors included financial resources, transportation, self-advocacy, health literacy, rural stoicism, personal agency, and cost of care. Interpersonal factors included factors such as ineffective relationships, poor communication, and care provider accessibility. Organisational factors included inequitable distribution of services, under-resourcing of perinatal services in rural areas, technology-enabled care models and access to continuity of care. Community factors included effective or ineffective interprofessional or interorganisational collaboration. Policy factors included centralisation of perinatal care, lack of funded homebirth and midwifery care pathways and access to free perinatal care., Conclusion: Participants in this study articulated several key barriers influencing access to perinatal care in rural areas. These factors impede help-seeking behaviour and engagement with care providers, compounding the impact of rurality and isolation on perinatal outcomes and experience of care. Key enablers to accessing perinatal care in rural communities were also identified and included personal agency, health literacy, social capital, effective collaboration and communication between clinicians and services, technology enabled care and free perinatal care., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interests., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: To identify perceived barriers and enablers for rural women in accessing perinatal care within their own community from the perspective of perinatal health care providers., Design: A qualitative descriptive study design utilising reflexive thematic analysis, using the socioecological framework to organise and articulate findings., Setting: Victoria, Australia., Participants: Semi-structured interviews were conducted with nine perinatal health care providers who provide care to pregnant women or new mothers in rural communities. Participants were recruited across Victoria in 2023., Results: Providers reported multi-level barriers and enablers that exist for rural women in accessing perinatal care within their communities. Barriers included women's personal circumstances, challenging professional relationships, inequitable service provision, ineffective collaboration between services and clinicians and government funding models and policies. Enablers included strength and resilience of rural women, social capital within rural communities, flexible care delivery and innovative practice, rural culture and continuity of care models., Conclusion: Rural perinatal health care providers perceived that rural women face multiple barriers that are created or sustained by complex interpersonal, organisational, community and policy factors that are intrinsic to rural health care delivery. Several addressable factors were identified that create unnecessary barriers for rural women in engaging with perinatal care. These included education regarding health systems, rights and expectations, equitable distribution of perinatal services, improved interprofessional relationships and collaborative approaches to care and equity-based funding models for perinatal services regardless of geographical location., (© 2024 The Author(s). Australian Journal of Rural Health published by John Wiley & Sons Australia, Ltd on behalf of National Rural Health Alliance Ltd.)

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.)

Purpose: Common mental disorders (non-psychotic mental health conditions which impact on day-to-day functioning) are increasingly common in childbearing women and may impact significantly on both maternal and neonatal outcomes. Our study examines the associations between common mental disorders and perinatal outcomes., Methods: We used routinely collected perinatal data (2009-2016) for this population-based retrospective cohort study (n = 597,522 singleton births). We undertook multiple logistic regression adjusting for key maternal medical conditions and sociodemographic factors to determine associations between maternal common mental disorders and adverse perinatal outcomes with confidence intervals set at 95%., Results: Women with common mental disorders were more likely to have an induction of labour and caesarean birth, have a postpartum haemorrhage (PPH), and be admitted to the Intensive Care Unit (ICU) than women without common mental disorders. Neonates of women with common mental disorders were more likely to have an Apgar score at five minutes of less than seven (a measure of neonatal wellbeing at birth), be born preterm and low birthweight, be admitted to the Special Care Nursery or Neonatal Intensive Care Unit (SCN/NICU) and have a congenital anomaly than neonates of women without common mental disorders., Conclusion: Common mental disorders during the perinatal period were associated with poorer perinatal outcomes for mothers and their neonates. Strategies that enable early recognition and response to maternal common mental disorders should be developed to mitigate the consequential impact on maternal and infant wellbeing., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: To examine the perinatal outcomes of women who experience social disadvantage using population-based perinatal data collected between 1999 and 2016., Design: Population-based, retrospective cohort study., Setting: Victoria, Australia., Population or Sample: A total of 1 188 872 singleton births were included., Methods: Cohort study using routinely collected perinatal data. Multiple logistic regression was performed to determine associations between social disadvantage and adverse maternal and neonatal outcomes with confidence limits set at 99%. Time-trend analysis for perinatal outcomes was performed in relation to area-level disadvantage measures., Main Outcome Measures: Incidence of maternal admission to intensive care unit (ICU), postpartum haemorrhage (PPH) and caesarean section, perinatal mortality, preterm birth, low birthweight (LBW), and admission to special care nursery/neonatal intensive care unit (SCN/NICU)., Results: Social disadvantage was associated with higher odds of adverse perinatal outcomes. Disadvantaged women were more likely to be admitted to ICU, have a PPH or experience perinatal mortality (stillbirth or neonatal death) and their neonates were more likely to be admitted to SCN/NICU, be born preterm and be LBW. A persistent social gradient existed across time for the most disadvantaged women for all outcomes except caesarean section., Conclusions: Social disadvantage has a marked negative impact on perinatal outcomes. This aligns with national and international evidence regarding the impact of disadvantage. Strategies that improve access to, and reduce fragmentation in, maternity care in addition to initiatives that address the social determinants of health may contribute to improving perinatal outcomes for socially disadvantaged women., (© 2023 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd.)

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.)

Aims and Objectives: To explore maternal and child health nurses' experiences of supporting women with postnatal depression and anxiety and the factors which impact these., Background: Maternal and child health nurses play a key role in identifying women with postnatal depression and anxiety and facilitating their access to appropriate supports. Understanding how nurses carryout this work, and the conditions which impact their ability to do so, is critical to the development of service delivery frameworks that can facilitate optimal outcomes for women and their families. Despite this, little is known about this subject., Design: A qualitative descriptive study., Methods: Participants were maternal and child health nurses practicing for at least six months and regularly seeing new mothers in Victoria, Australia. Twelve nurses were interviewed. Thematic analysis was conducted to identify patterns across our data. Qualitative content analysis was used to identify issues which were most emphasised by nurses. Reporting complies with the COREQ checklist., Findings: Three overarching themes were identified. Theme one pertained to steps taken by nurses following the identification of depression or anxiety symptoms and the shared challenges they encountered. Theme two concerned nurses' experiences of supporting women who required acute mental health interventions and the systemic barriers they faced. Finally, theme three related to how the existing service delivery model could be improved to better support nurses in their work., Conclusions: The complex system within which nurses operate presents barriers that can impede their ability to respond to women with postnatal mental health issues. There is a need for service delivery frameworks that better support nurses and facilitates equitable access to mental healthcare., Relevance to Clinical Practice: Facilitating equitable access to all perinatal mental health services and interventions must be at the heart of all future policy, funding and service delivery frameworks., (© 2022 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

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: Burnout is an occupational phenomenon with the potential to affect a person's physical and mental health, job satisfaction and quality of work. There is evidence of burnout occurring in the midwifery profession, but inadequate data on the prevalence of, and the factors associated with, burnout., Aim: Identify the prevalence of burnout in a population of midwives and explore what individual and workforce characteristics, and what occupational stressors, were associated with burnout., Methods: A cross-sectional survey of permanently employed midwives was conducted in a tertiary maternity service in Melbourne, Australia in 2017. Data collected included individual and workforce-related characteristics and occupational stressors. Burnout was explored using the Copenhagen Burnout Inventory. Univariate and multivariate analyses were conducted to ascertain associations between respondents' characteristics, stressors, and burnout levels., Findings: A total of 257/266 midwives (97%) responded. There were significant levels of exhaustion and fatigue among respondents; 68% of midwives were experiencing personal burnout, 51% work-related burnout, and 10% were experiencing client-related burnout. Being aged ≤ 35 years, and/or having inadequate support was associated with personal and work-related burnout. Having inadequate acknowledgement was associated with client-related burnout., Conclusion: Health services need to understand the risk factors for burnout among midwives, identify and support groups that are most vulnerable, and address areas that are amenable to intervention. In our context this means ensuring midwives receive adequate acknowledgement and support, particularly younger midwives. These findings need to be tested in other settings to help inform a broader understanding and ensure the sustainability of the midwifery profession., Competing Interests: Conflict of interest None declared., (Crown Copyright © 2022. Published by Elsevier Ltd. All rights reserved.)

How women are cared for while pregnant and having a new baby can have profound and lasting effects on their health and well-being. While mainstream maternity care systems aspire to provide care that is woman-centred, women with fewest social and economic resources often have reduced access. Community-based doula support programs offer complementary care for these women and are known to, on average, have positive outcomes. Less understood is how, when and why these programs work. A realist evaluation of an Australian volunteer doula program provided for women experiencing socioeconomic adversity explored these questions. The program provides free non-medical, social, emotional, and practical support by trained doulas during pregnancy, birth and new parenting. This paper reports the testing and refinement of one program theory from the larger study. The theory, previously developed from key informant interviews and rapid realist review of literature, hypothesised that the cultural matching of woman (client) and doula led to best outcomes. This was tested in realist interviews with women and focus groups with doulas, in January-February 2020. Seven English speaking, and six Arabic speaking clients were interviewed. Two focus groups were conducted with a total of eight doulas from diverse cultural and professional backgrounds. Data were analysed in NVivo. The study found cultural matching to be valued by some but not all women, and only when the doula was also genuinely interested, kind, timely and reliable. These approaches (with or without cultural matching) generate trust between the doula and woman. Trust theory, reflexivity theory and social relations theory supported explanatory understanding of the causal contribution of a doula knowing what it takes to build trust, to a woman deciding to trust her doula., (© 2022 The Authors. Health and Social Care in the Community published by John Wiley & Sons Ltd.)

In Victoria, Australia, Maternal and Child Health nurses (MCHNs) play a key role in facilitating the timely identification of Postnatal Depression and Anxiety (PNDA). Understanding MCHNs' screening practices, and the factors which impact them, is central to ensuring that future screening policy agendas are evidence-based and able to support MCHNs in carrying out this critical work. Yet, little is known about this subject. The purpose of this study was to gain an in-depth understanding of MCHNs' screening practices, and the factors which impact them. Qualitative descriptive design with semi-structured interviews were used. Participants were MCHNs who had been practicing for a minimum of 6 months and regularly saw new mothers. Purposeful sampling was used to facilitate diversity across participant characteristics. Twelve MCHNs were interviewed between March and May 2021. Thematic analysis was conducted to identify patterns across our data. Qualitative content analysis was then used to identify issues which were most emphasised by MCHNs. Two themes were identified. Theme one, 'variations in screening practices', pertained to MCHNs' various screening practices (i.e., who, when, how) and the factors which influence them. Theme two, 'systemic barriers hinder equitable screening', pertained to factors which hindered equitable screening practices. Results indicate that systemic barriers contribute to inconsistent and inequitable screening practices, with women from culturally and linguistically diverse backgrounds less likely to be screened in line with best practice. Our findings emphasise an urgent need for MCHNs to be allocated with the resources required to screen all women equally, regardless of their cultural background., (© 2022 The Authors. Health and Social Care in the Community published by John Wiley & Sons Ltd.)

Objectives: To describe Maternal and Child Health nurses' self-reported knowledge of, and attitude toward screening for postnatal depression and anxiety, and identify factors which impact screening in line with recommended guidelines., Methods: A population-based, cross-sectional study of all Maternal and Child Health nurses in Victoria, Australia. Data were collected in 2019 through an online survey designed to fit a Knowledge, Attitude and Practice framework. Descriptive analyses were conducted to describe participant characteristics, self-reported knowledge, attitude, and practices. Bivariate and multivariate regression analysis were performed to evaluate associations between screening practices and nurses' attitude toward screening and a range of sociodemographic variables., Results: Two hundred and eighteen Maternal and Child Health nurses participated in the study. Participants viewed screening as an important part of their role and screened all mothers at least once in the first 12 month postpartum. <35% routinely did so more than once in the first 12 months postpartum, and 31% were able to adhere to the recommended use of psychosocial assessments as part of their screening practice. After adjusting for confounding factors, nurses practicing in communities with greater socio-economic advantage were significantly more likely to conduct psychosocial assessments (aOR 3.93, 95% CI 1.47-10.49) and screen more than once (aOR 2.91, 95% CI 1.18-7.13), compared to nurses who worked in disadvantaged communities., Conclusion: Place-based inequities in nurses' screening practices serve to widen the gap in health outcomes between advantaged and disadvantages mothers. Policy and practice strategies must consider the systematic challenges that contribute to this phenomenon and embed place-based strategies which address them., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier B.V. All rights reserved.)

How women are cared for while having a baby can have lasting effects on their lives. Women value relational care with continuity-when caregivers get to know them as individuals. Despite evidence of benefit and global policy support, few maternity care systems across the world routinely offer relational continuity. Women experiencing socioeconomic adversity have least access to good quality maternity care. Community-based doula support programs offer complementary care for these women and are known to, on average, have positive outcomes. Less understood is how, when, and why these programs work. A realist evaluation of an Australian volunteer doula program explored these questions. The program provides free social, emotional, and practical support by trained doulas during pregnancy, birth, and early parenting. This paper reports the testing and refinement of one program theory from the larger study. The theory, previously developed from key informant interviews and rapid realist review of literature, hypothesised that support increased a woman's confidence via two possible pathways-by being with her and enabling her to see her own strength and value; and by praising her, and her feeling validated as a mother. This study aimed to test the theory in realist interviews with clients, focus groups with doulas, and with routinely collected pre-post data. Seven English-speaking and six Arabic-speaking clients were interviewed, and two focus groups with a total of eight doulas were conducted, in January-February 2020. Qualitative data were analysed in relation to the hypothesised program theory. Quantitative data were analysed for differential outcomes. Formal theories of Recognition and Relational reflexivity supported explanatory understanding. The refined program theory, Recognition, explains how and when a doula's recognition of a woman, increases confidence, or not. Five context-mechanism-outcome configurations lead to five outcomes that differ by nature and longevity, including absence of felt confidence., Competing Interests: The authors have declared that no competing interests exist.

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).)

Background: Significant factors affecting the Australian maternity care context include an ageing, predominantly part-time midwifery workforce, increasingly medicalised maternity care, and women with more complex health/social needs. This results in challenges for the maternity care system. There is a lack of understanding of midwives' experiences and job satisfaction in this context., Aim: To explore factors affecting Australian midwives' job satisfaction and experience of work., Methods: In 2017 an online cross-sectional questionnaire was used to survey midwives employed in a tertiary hospital. Data collected included characteristics, work roles, hours, midwives' views and experiences of their job. The Midwifery Process Questionnaire was used to measure midwives' satisfaction in four domains: Professional Satisfaction, Professional Support, Client Interaction and Professional Development. Data were analysed as a whole, then univariate and multivariate logistic regression analyses conducted to explore any associations between each domain, participant characteristics and other relevant factors., Findings: The overall survey response rate was 73% (302/411), with 96% (255/266) of permanently employed midwives responding. About half (53%) had a negative attitude about their Professional Support and Client Interaction (49%), and 21% felt negatively about Professional Development. The majority felt positively regarding Professional Satisfaction (85%). The main factors that impacted midwives' satisfaction was inadequate acknowledgment from the organisation and needing more support to fulfil their current role., Conclusion: Focus on leadership and mentorship around appropriate acknowledgement and support may impact positively on midwives' satisfaction and experiences of work. A larger study could explore how widespread these findings are in the Australian maternity care setting., (Copyright © 2021 Australian College of Midwives. Published by 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.)

Objective: To examine the range and nature of primary research evidence on postnatal depression and anxiety screening and management by maternal and child health nurses within community settings., Background: Maternal and child health nurses are well-placed to identify and support women at risk of, or experiencing, postnatal depression and anxiety- a prevalent public health issue which remains largely undetected., Methods: Scoping methodology, guided by the Arksey and O'Malley (2005) framework, was used. The following electronic databases were searched in June 2019 and again in July 2020: Cumulative Index of Nursing and Allied Health Literature, MEDLINE, PsycINFO, and COCHRANE Library. Primary studies that were published in English, between 2008 and 2020, were included. PRISMA checklist and PRISMA flow diagram were used to adhere to best practice guidelines., Results: Twenty-three articles, relating to 22 studies, met the inclusion criteria. Two principal themes were identified: 'screening for postnatal depression and anxiety' and 'factors that influence postnatal depression and anxiety management'. Subthemes in the former related to attitudes toward screening, routine screening practice, screening efficacy, and attitudes toward the Edinburgh Postnatal Depression Scale. Subthemes in the latter included availability of formal care pathways, referral options, knowledge and confidence, and multiagency collaboration., Conclusions and Relevance to Clinical Practice: While maternal and child health nurses value their role in identifying and supporting mothers at risk of postnatal depression and anxiety, certain individual and organisational factors contribute to a gap between best practice and clinical practice. Narrowing the gap between evidence and practice is unlikely without directly addressing these barriers. Gaps in maternal and child health nurses' knowledge, skills and confidence regarding effective screening and management of mothers experiencing, or at risk of, postnatal depression and anxiety, impacts the quality of care provided. Ongoing training and professional development which adequately addresses these gaps is required., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

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.)

Problem: Volunteer doula support has achieved favourable outcomes for socially disadvantaged women around the world. There is limited explanatory understanding of how, why and when doula support programs improve outcomes., Background: A community organisation is providing free doula support for women experiencing socioeconomic disadvantage in Melbourne, Australia. The program aims to complement the mainstream maternity care system, to promote equity in women's care, and experiences of pregnancy, birth and early parenting. This program is the first of its kind in Australia and has not previously been evaluated., Aim: To develop hypothesised program theories for the realist evaluation of an Australian doula program., Methods: As the first stage of a realist evaluation, three key informant interviews and rapid realist review of literature were conducted in December 2017 - January 2019., Findings: Seven theories were developed in four categories: critical elements of implementation (Attracting and activating the right doulas, and Good matching); outcomes for women (Being by her side, and Facilitating social connection), outcomes in maternity care system (Complementing or enhancing maternity care, and Doula as a witness - demanding accountability in others), and outcomes for doulas (Doulas as beneficiaries). These theories were framed in accordance with a realist understanding of causation, as Context - Mechanism - Outcome (CMO) configurations., Discussion and Conclusion: The development of theories from multiple sources of evidence provides a strong theoretical base for program evaluation. The theories hypothesise how, why, for whom and when the doula program works. Subsequent stages of the evaluation will test and refine the theories., (Copyright © 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

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.

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.)

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: 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: 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: 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., (© 2015 Royal College of Obstetricians and Gynaecologists.)