THE ABLE STUDY (ASKING WOMEN ABOUT DISABILITIES): Exploring the prevalence and experiences of women with disabilities who use maternity services at The Royal Women’s Hospital
It is estimated that more than one billion people worldwide are living with a disability. However, limited information exists on the disability status and needs of women during pregnancy. In Australia, disability status is not included in the Perinatal National Minimum Data Set. While there is a limited amount of qualitative research focusing on the experiences of pregnancy and childbirth of women with a disability, there is an absence of quantifiable data. We aim to address this gap by exploring the prevalence and identification of women with disabilities who utilise maternity services. We will also gain insight into the experiences of women who identify as having a disability about how they found their pregnancy, labour and birth and the early postnatal period.
BAGGARROOK YURRONGI: Improving the health of Aboriginal mothers and babies through continuity of midwife care
The Baggarrook Yurrongi (Woiwurrung language of the Wurundjeri people) meaning ‘Woman’s Journey’ and the Nuraagh Manma Buliana (Yorta Yorta language) meaning ‘All of us working together in pregnancy’ is a 5-year NHMRC funded Partnership Project with the Victorian Aboriginal Community Controlled Health Organisation (VACCHO), the Royal Women’s Hospital, the Mercy Hospital for Women, Sunshine Hospital and Goulburn Valley Health. The study is evaluating the effect of continuity of midwifery care in pregnancy, labour, birth and the postnatal period (called caseload midwifery) on perinatal outcomes for Aboriginal women and their infants. Our previous research (the COSMOS trial) found that caseload improves maternal and infant outcomes, and this care model is now regarded as the gold standard. Yet many eligible Aboriginal and Torres Strait Islander pregnant women are not offered caseload care. The aim of the project is to help close the gap in access to this model of care and improve the health outcomes for Aboriginal women and their babies. Highlights of the project to date include the successful introduction of the model at the Royal Women’s in March 2017. Since the introduction of the model there has been a more than 10-fold increase in the number of Aboriginal women having access to caseload midwifery. A key aspect of the successful implementation of the program has been the collaboration, communication and partnership with Aboriginal, hospital and community partners.
DAISY: Depression and AnxIety peer Support studY: a randomised controlled trial
Depression and anxiety are very common issues that affect women after they have had a baby, and in Australia at least 68,000 new mothers experience one or both of these each year. These conditions can lead to serious adverse consequences for a mother’s health and the health of her infant and family. However, one in three Victorian new mothers experiencing postnatal depression does not seek help.
The Daisy study is a multi-site, two arm randomised controlled trial (RCT) matching peer volunteer mothers with a lived experience of postnatal depression and/or anxiety (from which they have recovered) with new mothers at increased risk of postnatal depression or anxiety. The new mothers, who are at slightly higher risk than average of developing depression and/or anxiety, are recruited from the postnatal units at the Women’s hospital. Mothers allocated to peer support receive proactive telephone-based support from a peer volunteer up until six months postpartum, and both groups receive all the usual care and supports available as part of routine care. We will recruit 1,060 women to the study, and aim to train about 200 peer volunteer mothers to provide the telephone support.
We will test whether proactive peer support by telephone decreases the risk of postnatal depression at six months postpartum, and a range of other health outcomes will also be measured, along with exploring the cost-effectiveness of such a service.
DIABETES AND ANTENATAL MILK EXPRESSING (DAME): a randomised controlled trial
This world first study has found that women with diabetes in a low-risk pregnancy can safely express breast milk in late pregnancy, with the study dispelling concerns that the practice could cause harm to babies. The DAME study explored the safety and effectiveness of advising women with diabetes in pregnancy to commence expressing breast milk from 36 weeks of pregnancy. We recruited a total of 635 women and randomised them to the study – about half of them were advised to express. We recruited the women at six sites that provide pregnancy and birth care: The Royal Women’s Hospital, Mercy Hospital for Women, Monash Health, Barwon Health, the Women’s at Sandringham (part of the Royal Women’s Hospital) and Frankston Hospital, from June 2011 until October 2015. We collected data at recruitment in late pregnancy as well as from birth records, and then by telephone interview at two weeks and 12 weeks after birth. The study found that for women with diabetes in pregnancy who were considered of low obstetric risk, there was no harm in advising them to express breast milk in late pregnancy. We also found evidence that infants were more likely to receive only breast milk in the first 24 hours after birth. The findings pave the way for clinicians to recommend that low-risk pregnant women with diabetes in pregnancy express and store breast milk to give to their newborns in the event they develop hypoglycaemia (low blood sugar levels) – a condition that can cause serious health problems in newborns. The results of our study should not be extrapolated to high-risk groups with diabetes in pregnancy. The study results were published in The Lancet in 2017, and clinical guidelines have been developed based on the study outcomes. A sub-study titled Exploring mothers’ perceptions of their experience of antenatal milk expressing commenced in early 2017.
EVALUATION OF THE GROWING TOGETHER PARENTING KIT: a mixed methods study
The Royal Women’s Hospital developed an educational kit for pregnant women about early parenting, known as Growing Together, with funding from the Victorian State Government. The kit has three components – an information book for parents that covers the journey from conception to one year of age, an App that has been specifically designed for the project, and a children’s book that parents are encouraged to read to their infants. We evaluated the kit using mixed methods, measuring a range of outcomes including parents’ views and experiences of the care and information, women’s experience of motherhood, attachment, infant development, and parental knowledge and confidence as well as the views and experiences of health professionals.
EXPert – Exploring midwives’ and nurses’ perceptions of expertise and what it is like to work at the Women’s
In Australia the concept of ‘expertise’ within the midwifery and nursing workforce is traditionally based on number of years that the clinician has been practicing. As the number of years in the workforce increases so does the level of compensation, possibly furthering the view that the longer staff have worked the more skilled they are and the more ‘valuable’ they are. However it may be that when managers are organising staffing they may consider each staff member not simply based on the number of years they have been practicing, but also in terms of how much of an ‘expert’ they are. At the same time, at the Women’s, there has been an increase in the number of ‘early career’ staff – those registered five years or less, and they make up an increasing proportion of the workforce.
Along with these issues, before this study was conceived, there had been anecdotal reports in recent years of the midwives’ and nurses’ at the Women’s expressing they were experiencing a high level of stress and dissatisfaction about some aspects of their work. There were also some concerns about staff retention. Given these anecdotal reports, it was important to undertake some focused research into how midwives and nurses were actually feeling – to explore if these issues were a concern, and to find out how widespread any issues were. We also wanted to understand what factors the midwives and nurses felt positively or negatively affected their experience at work. The purpose of the EXPert study is to develop a functional definition of expertise within the midwifery and nursing workforce (that can be applied to recruitment, rostering, supporting staff, skill mix, and workforce strategies) and to explore midwives’ and nurses’ experience of work at the Women’s and what factors affect their experience.
A series of focus groups were conducted in 2016, and then a cross-sectional survey developed based on the findings of the focus groups. The survey was undertaken in 2017 and the results are being currently analysed and translated to practice.
GEM CARE- Exploring the feasibility and acceptability of group antenatal care and education: a pilot randomised controlled trial
Group-based antenatal care is a new approach to the provision of pregnancy care and education that involves the integration of antenatal care, childbirth preparation and early parenting education into group sessions for pregnant women. Care and education is provided in two-hour sessions with a group of 8-10 women, for 6-8 sessions. Each group is facilitated by two midwives who remain with the group for all sessions, to allow for continuity and teamwork. Current evidence is inconclusive, but some studies report an association with less preterm birth. A Systematic review of group antenatal care concluded that further high quality research is needed to determine whether group antenatal care is of benefit. No adverse outcomes were found for women randomised to group antenatal care, nor for their babies, and the care was viewed positively by women.
We tested the feasibility of implementing an adequately powered randomised controlled trial (RCT). Women were randomised to either to the intervention received group-based antenatal care and education; or usual care included hospital-based midwife, caseload, small team care, or shared care with a GP. Participants were English-speaking, primiparous, low risk, and < 25 weeks gestation at booking. Clinical outcome data were collected from the medical record, and a telephone interview six weeks postpartum explored women’s views.
The pilot is complete with 74 women recruited from May to June 2017 (group care = 40, usual care = 34). Further results are being analysed with a view to publish and secure funding for a larger adequately powered two-arm multi-site RCT.
IVY – Investigating an online community of support for emotional health in pregnancy
Perinatal mental illness is a major public health issue, with serious and costly health consequences for women, their infants and families. Many women don’t seek help; potential barriers include fear of stigmatisation, fear of failure and lack of support. These barriers may be overcome by more flexible models of support, such as an online peer support program. This study aims to develop and test the feasibility, acceptability and functionality of a moderated online peer support App to be used on smart phones, tablets or computers, to reduce perinatal depression and anxiety in women at increased risk. The project has been undertaken in collaboration with PANDA –Perinatal Anxiety & Depression Australia – Australia’s peak consumer perinatal mental health organisation. An iterative user-centred approach was used to design and develop the App, via a series of interviews, focus groups and design workshops with consumers, stakeholders and software designers. We are preparing to conduct a pilot randomised controlled trial (RCT) to test potential impact and engagement as well as to inform a large adequately powered RCT.
MATERNITY AND NEWBORN EMERGENCIES (MANE) – program evaluation
The Victorian Department of Health and Human Services has funded the Maternity and Newborn Emergencies (MANE) program, which is auspiced and run by The Royal Women’s Hospital Maternity Services Education Program for regional and rural public maternity providers. To inform the ongoing development of the content, design and delivery of the program, we are conducting an evaluation of MANE over a three-year period from 2017 to 2020. All rural and regional maternity service providers currently receiving MANE have the opportunity to participate, with in-depth case studies conducted at five maternity service sites
RUBY- 'Ringing up about breastfeeding’
The RUBY (Ringing Up about Breastfeeding earlY) study 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. RUBY was a multicentre, randomised controlled trial conducted in three hospitals in Victoria, between February 2013 and December 2015. Over 1150 first-time mothers intending to breastfeed were recruited at one of the three hospitals (Royal Women’s, Monash Health, Western Health Sunshine) after birth and prior to hospital discharge. They were randomly assigned to usual care or usual care plus proactive telephone-based breastfeeding support from a trained peer volunteer for up to six months postpartum.
The study found that 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%).
UNDERSTANDING COMMUNITY ATTITUDES AND IDENTIFYING DESIGN SOLUTIONS TO INCREASE WOMEN’S COMFORT WITH BREASTFEEDING IN PUBLIC
This project explores design features and community attitudes that invite or deter breastfeeding in public. We conducted interviews and focus groups with breastfeeding mothers in three local government areas in 2016 (Rural City of Swan Hill, City of Greater Bendigo and City of Melbourne) and at The Royal Women’s Hospital in 2018. We received input from over 80 mothers speaking five languages, as well as health professionals and council planning staff. Using these data, we have developed design guidelines that outline how a range of everyday shared spaces could become breastfeeding-friendly as well as the optimal design characteristics for dedicated breastfeeding spaces.
YOUR VIEWS MATTER – Exploring the views and experiences of parents of infants in Neonatal Intensive and Special Care (NISC)
Consumer satisfaction is now a fundamental aspect of evaluating the delivery of health care services in today’s society. Traditionally, long term outcomes of neonatal intensive care were measured mainly in relation to clinical indicators, but consumer satisfaction is increasingly becoming a quality of care indicator for paediatric and neonatal units. Past explorations of families’ experiences of neonatal care, at the Women’s, has been limited and have not included all families whose babies have been admitted to the NISC.
The aim of the current study was to explore the satisfaction, experiences and needs of parents whose babies have been admitted to the NICU at the Women’s, in order to inform the way future care is provided.
A cross-sectional survey was undertaken from March 2017 to June 2018. Families who had a baby or babies admitted to the NICU between September 1st 2016 and June 26th 2017 were assessed for eligibility (admission ≥ 4 hours and discharge from NICU at 6 months of age). Eligible families were sent a survey in the mail followed by 3 reminders. Families who have experienced the death of their baby during their admission were also included in the study and were sent an invitation to participate, followed by a modified survey if they indicated they would like to participate. A total of 1014 surveys (or invitations to participate) were sent (990 non-bereaved families; 24 bereaved families). Of these 316 surveys were returned – 31% (312/990) non-bereaved families and 57% (4/7) of bereaved families who indicated they wanted to participate.
Results are currently being analysed and plans for dissemination of results are being made.