Sue Kildea

Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial

BACKGROUND Women at low risk of pregnancy complications benefit from continuity of midwifery care, but no trial evidence exists for women with identified risk factors. We aimed to assess the clinical and cost outcomes of caseload midwifery care for women irrespective of risk factors. METHODS In this unblinded, randomised, controlled, parallel-group trial, pregnant women at two metropolitan teaching hospitals in Australia were randomly assigned to either caseload midwifery care or standard maternity care by a telephone-based computer randomisation service. Women aged 18 years and older were eligible if they were less than 24 weeks pregnant at the first booking visit. Those who booked with another care provider, had a multiple pregnancy, or planned to have an elective caesarean section were excluded. Women allocated to caseload care received antenatal, intrapartum, and postnatal care from a named caseload midwife (or back-up caseload midwife). Controls received standard care with rostered midwives in discrete wards or clinics. The participant and the clinician were not masked to assignment. The main primary outcome was the proportion of women who had a caesarean section. The other primary maternal outcomes were the proportions who had an instrumental or unassisted vaginal birth, and the proportion who had epidural analgesia during labour. Primary neonatal outcomes were Apgar scores, preterm birth, and admission to neonatal intensive care. We analysed all outcomes by intention to treat. The trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12609000349246. FINDINGS Publicly insured women were screened at the participating hospitals between Dec 8, 2008, and May 31, 2011. 1748 pregnant women were randomly assigned, 871 to caseload and 877 to standard care. The proportion of caesarean sections did not differ between the groups (183 [21%] in the caseload group vs 204 [23%] in the standard care group; odds ratio [OR] 0·88, 95% CI 0·70-1·10; p=0·26). The proportion of women who had elective caesarean sections (before onset of labour) differed significantly between caseload and standard care (69 [8%] vs 94 [11%]; OR 0·72, 95% CI 0·52-0·99; p=0·05). Proportions of instrumental birth were similar (172 [20%] vs 171 [19%]; p=0·90), as were the proportions of unassisted vaginal births (487 [56%] vs 454 [52%]; p=0·08) and epidural use (314 [36%] vs 304 [35%]; p=0·54). Neonatal outcomes did not differ between the groups. Total cost of care per woman was AUS

The role of the midwife in Australia: views of women and midwives

566·74 (95% 106·17-1027·30; p=0·02) less for caseload midwifery than for standard maternity care. INTERPRETATION Our results show that for women of any risk, caseload midwifery is safe and cost effective. FUNDING National Health and Medical Research Council (Australia).

Reproductive health, infertility and sexually transmitted infections in indigenous women in a remote community in the Northern Territory.

OBJECTIVE to research the role of midwives in Australia from the perspectives of women and midwives. This study was part of a commissioned national research project to articulate the scope of practice of Australian midwives and to develop national competency standards to assist midwives to deliver safe and competent midwifery care. DESIGN a multi-method approach with qualitative data collected from surveys with women and interviews with midwives. SETTING participants represented each state and territory in Australia. PARTICIPANTS midwives who were randomly selected by the regulatory authorities across the country and women who were consumers of midwifery care and involved in maternity activism. KEY CONCLUSIONS midwives and women identified a series of key elements that were required of a midwife. These included: being woman centred; providing safe and supportive care; and working in collaboration with others when necessary. These findings were consistent with much of the international literature. IMPLICATIONS FOR PRACTICE a number of barriers to achieving the full role of the midwife were identified. These included a lack of opportunity to practice across the full spectrum of maternity care, the invisibility of midwifery in regulation and practice, the domination of medicine, workforce shortages, the institutional system of maternity care, and the lack of a clear image of what midwifery is within the wider community. These barriers must be addressed if midwives in Australia are to be able to function according to the full potential of their role.

Risky business: contested knowledge over safe birthing services for Aboriginal women

Objective: To investigate markers of reproductive health in a remote Indigenous community in Northern Australia.

Niyith Nniyith Watmam (the quiet story): Exploring the experiences of Aboriginal women who give birth in their remote community

Abstract Maternity services in Australia are becoming rationalised with contemporary, authoritative knowledge driving the provision of services under the premise that birth in larger regional and tertiary settings is the safest option. There is increasing evidence that families who live in rural and remote areas are not satisfied with having to travel long distances and be absent from their homes for weeks at a time for childbirth. This is particularly problematic for remote dwelling Aboriginal women, with evidence suggesting current maternity services and relocation for birth are culturally, socially and emotionally unsatisfactory and unsafe. The Indigenous knowledge around birthing that still exists in remote communities today, is not being acknowledged or incorporated into health service provision with the current ‘risk equation’ excluding the social, emotional and cultural risks that have been identified by the women themselves. Unlike the Inuit situation in Canada, which could provide leadership and advice for Australia, there has not been sufficient dialogue in Australia around the construction of risk and its importance in the birthing environment, particularly for Aboriginal women.

Does the way maternity care is provided affect maternal and neonatal outcomes for young women? A review of the research literature

OBJECTIVE to investigate the beliefs and practices of Aboriginal women who decline transfer to urban hospitals and remain in their remote community to give birth. DESIGN an ethnographic approach was used which included: the collection of birth histories and narratives, observation and participation in the community for 24 months, field notes, training and employment of an Aboriginal co-researcher, and consultation with and advice from a local reference group. SETTING a remote Aboriginal community in the Northern Territory, Australia. PARTICIPANTS narratives were collected from seven Aboriginal women and five family members. FINDINGS findings showed that women, through their previous experiences of standard care, appeared to make conscious decisions and choices about managing their subsequent pregnancies and births. Women took into account their health, the babys health, the care of their other children, and designated men with a helping role. KEY CONCLUSIONS narratives described a breakdown of traditional birthing practices and high levels of non-compliance with health-system-recommended care. IMPLICATION FOR PRACTICE standard care provided for women relocating for birth must be improved, and the provision of a primary maternity service in this particular community may allow Aboriginal Womens Business roles and cultural obligations to be recognised and invigorated. International examples of primary birthing services in remote areas demonstrate that they can be safe alternatives to urban transfer for childbirth. A primary maternity service would provide a safer environment for the women who choose to avoid standard care.

Modulation of resting brain cerebral blood flow by the GABA B agonist, baclofen: A longitudinal perfusion fMRI study

BACKGROUND Young pregnant women who continue a pregnancy are primarily from a socioeconomically deprived background. The risk factors associated with low socio-economic status may independently affect perinatal and neonatal morbidity to a greater extent than the young age of the woman. Young pregnant women are frequently sceptical about health care providers who they can perceive to be judgemental. This may lead to late booking for pregnancy care, attending few appointments, or not attending the health service for any antenatal care. QUESTION Does the way maternity care is provided affect maternal and neonatal outcomes for young women? METHOD A systematic search of the major health databases. RESULTS Nine research articles met the eligibility criteria: one randomised controlled trial, three prospective cohort studies, two comparative studies with concurrent controls, two comparative studies with historical controls, and one case series. DISCUSSION Providing young women with a non-standard model of maternity care has some beneficial and no known detrimental effects on childbirth outcomes. While there is a dearth of evidence on the effectiveness of a Midwifery Group Practice model of care for young women, there is strong evidence to suggest that a Group Antenatal Care model increases antenatal visit attendance and breastfeeding initiation, and decreases the risk of preterm birth. There is research to indicate that a Young Womens Clinic model may also increase antenatal visit attendance and decrease the incidence of preterm birth. CONCLUSION More well-designed and resourced midwifery models of care for young women should be implemented and rigorously researched.

From hospital to home: The quality and safety of a postnatal discharge system used for remote dwelling Aboriginal mothers and infants in the top end of Australia

BACKGROUND Preclinical studies confirm that the GABA B agonist, baclofen blocks dopamine release in the reward-responsive ventral striatum (VS) and medial prefrontal cortex, and consequently, blocks drug motivated behavior. Its mechanism in humans is unknown. Here, we used continuous arterial spin labeled (CASL) perfusion fMRI to examine baclofens effects on blood flow in the human brain. METHODS Twenty-one subjects (all smokers, 12 females) were randomized to receive either baclofen (80 mg/day; N=10) or placebo (N=11). A five minute quantitative perfusion fMRI resting baseline (RB) scan was acquired at two time points; prior to the dosing regimen (Time 1) and on the last day of 21 days of drug administration (Time 2). SPM2 was employed to compare changes in RB from Time 1 to 2. RESULTS Baclofen diminished cerebral blood flow (CBF) in the VS and mOFC and increased it in the lateral OFC, a region involved in suppressing previously rewarded behavior. CBF in bilateral insula was also blunted by baclofen (T values ranged from -11.29 to 15.3 at p=0.001, 20 contiguous voxels). CBF at Time 2 was unchanged in placebo subjects. There were no differences between groups in side effects or cigarettes smoked per day (at either time point). CONCLUSIONS Baclofens modulatory actions on regions involved in motivated behavior in humans are reflected in the resting state and provide insight into the underlying mechanism behind its potential to block drug-motivated behavior, in preclinical studies, and its putative effectiveness as an anti-craving/anti-relapse agent in humans.

A randomised controlled trial of caseload midwifery care: M@NGO (Midwives @ New Group practice Options)

OBJECTIVE to examine the transition of care in the postnatal period from a regional hospital to a remote health service and describe the quality and safety implications for remote dwelling Aboriginal mothers and infants. DESIGN a retrospective cohort study of maternal health service utilisation and birth outcomes, key informant interviews with health service providers and participant observation in a hospital and two remote health centres. Data were analysed using descriptive statistics and content analysis. SETTING a maternity unit in a regional public hospital and two remote health centres within large Aboriginal communities in the Top End of the Northern Territory, Australia. FINDINGS poor discharge documentation, communication and co-ordination between hospital and remote health centre staff occurred. In addition, the lack of clinical governance and a specific position holding responsibility for the postnatal discharge planning process in the hospital system were identified as serious risks to the safety of the mother and infant. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE the quality and safety of discharge practices for remote dwelling mothers and their infants in the transition from hospital to their remote health service following birth need to be improved. The discharge process and service delivery model must be restructured to reduce the adverse effects of poor standards of care on mothers and infants.

A population-based investigation into inequalities amongst Indigenous mothers and newborns by place of residence in the Northern territory, Australia

BackgroundAustralia has an enviable record of safety for women in childbirth. There is nevertheless growing concern at the increasing level of intervention and consequent morbidity amongst childbearing women. Not only do interventions impact on the cost of services, they carry with them the potential for serious morbidities for mother and infant.Models of midwifery have proliferated in an attempt to offer women less fragmented hospital care. One of these models that is gaining widespread consumer, disciplinary and political support is caseload midwifery care. Caseload midwives manage the care of approximately 35-40 a year within a small Midwifery Group Practice (usually 4-6 midwives who plan their on call and leave within the Group Practice.) We propose to compare the outcomes and costs of caseload midwifery care compared to standard or routine hospital care through a randomised controlled trial.Methods/designA two-arm RCT design will be used. Women will be recruited from tertiary womens hospitals in Sydney and Brisbane, Australia. Women allocated to the caseload intervention will receive care from a named caseload midwife within a Midwifery Group Practice. Control women will be allocated to standard or routine hospital care. Women allocated to standard care will receive their care from hospital rostered midwives, public hospital obstetric care and community based general medical practitioner care. All midwives will collaborate with obstetricians and other health professionals as necessary according to the womans needs.DiscussionData will be collected at recruitment, 36 weeks antenatally, six weeks and six months postpartum by web based or postal survey. With 750 women or more in each of the intervention and control arms the study is powered (based on 80% power; alpha 0.05) to detect a difference in caesarean section rates of 29.4 to 22.9%; instrumental birth rates from 11.0% to 6.8%; and rates of admission to neonatal intensive care of all neonates from 9.9% to 5.8% (requires 721 in each arm). The study is not powered to detect infant or maternal mortality, however all deaths will be reported. Other significant findings will be reported, including a comprehensive process and economic evaluation.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12609000349246