Evaluation of systems reform in public hospitals, Victoria, Australia, to improve access to antenatal care for women of refugee background: An interrupted time series design.

INTRODUCTION: Inequalities in maternal and newborn health persist in many high-income countries, including for women of refugee background. The Bridging the Gap partnership programme in Victoria, Australia, was designed to find new ways to improve the responsiveness of universal maternity and early child health services for women and families of refugee background with the codesign and implementation of iterative quality improvement and demonstration initiatives. One goal of this 'whole-of-system' approach was to improve access to antenatal care. The objective of this paper is to report refugee women's access to hospital-based antenatal care over the period of health system reforms. METHODS AND FINDINGS: The study was designed using an interrupted time series analysis using routinely collected data from two hospital networks (four maternity hospitals) at 6-month intervals during reform activity (January 2014 to December 2016). The sample included women of refugee background and a comparison group of Australian-born women giving birth over the 3 years. We describe the proportions of women of refugee background (1) attending seven or more antenatal visits and (2) attending their first hospital visit at less than 16 weeks' gestation compared over time and to Australian-born women using logistic regression analyses. In total, 10% of births at participating hospitals were to women of refugee background. Refugee women were born in over 35 countries, and at one participating hospital, 40% required an interpreter. Compared with Australian-born women, women of refugee background were of similar age at the time of birth and were more likely to be having their second or subsequent baby and have four or more children. At baseline, 60% of refugee-background women and Australian-born women attended seven or more antenatal visits. Similar trends of improvement over the 6-month time intervals were observed for both populations, increasing to 80% of women at one hospital network having seven or more visits at the final data collection period and 73% at the other network. In contrast, there was a steady decrease in the proportion of women having their first hospital visit at less than 16 weeks' gestation, which was most marked for women of refugee background. Using an interrupted time series of observational data over the period of improvement is limited compared with using a randomisation design, which was not feasible in this setting. CONCLUSIONS: Accurate ascertainment of 'harder-to-reach' populations and ongoing monitoring of quality improvement initiatives are essential to understand the impact of system reforms. Our findings suggest that improvement in total antenatal visits may have been at the expense of recommended access to public hospital antenatal care within 16 weeks of gestation.

Effects of mindfulness on maternal stress, depressive symptoms and awareness of present moment experience: A pilot randomised trial.

OBJECTIVE: To determine the feasibility and acceptability and measure the effects of a mindfulness intervention compared to a pregnancy support program on stress, depressive symptoms and awareness of present moment experience. DESIGN: A pilot randomised trial using mixed methods. PARTICIPANTS AND SETTING: Forty-eight women attending a maternity service were randomly allocated to a mindfulness-based or pregnancy support program. MEASURES: Perceived Stress Scale, Edinburgh Postnatal Depression Scale, Mindfulness Attention Awareness Scale, and Birth Outcomes. Women's perceptions of the impact of the programs were examined via summative evaluation, interviews, diaries and facilitator field notes. FINDINGS: Nine women in the mindfulness program and 11 in the pregnancy support program completed post-program measures. There were no statistically significant differences between groups. Of practical significance, was an improvement in measures for both groups with a greater improvement in awareness of present moment experience for the intervention group. The intervention group reported learning how to manage stressors, fear, anxiety, and to regulate their attention to be more present. The control group reported learning how to calm down when stressed which increased their confidence. Intervention group themes were: releasing stress, becoming aware, accepting, having options and choices, connecting and being compassionate. Control group themes were:managing stress, increasing confidence, connecting, focussing, being accepted, preparing. KEY CONCLUSION: The feasibility and acceptability of the intervention was confirmed. Programs decreased women's self-reported stress in different ways. Women in the mindfulness program accepted themselves and their experiences as they arose and passed in the present moment, while those in the control group gained acceptance primarily from external sources such as peers. IMPLICATIONS FOR PRACTICE: Mindfulness programs can foster an internalised locus of self-acceptance which may result in woman becoming less dependent on others for their wellbeing. Adequately powered RCTs, with an active control, long-term follow up and economic evaluation are recommended.

Poorer detection rates of severe fetal growth restriction in women of likely refugee background: A case for re-focusing pregnancy care.

BACKGROUND: Severe fetal growth restriction (FGR) (< third centile) in a singleton pregnancy undelivered by 40 weeks is one of a number of Victorian Perinatal Services Performance Indicators, which aim to provide a measure of the quality and safety of maternity care. Women of refugee background have been found to have poorer perinatal outcomes compared to others and these outcomes can in part be explained by previous history. However, less access to and engagement with pregnancy care may also be contributing factors. This study examined the impact of likely refugee background on severe FGR in a singleton pregnancy undelivered by 40 weeks. METHODS: A retrospective study was undertaken utilising data on women who gave birth to a severely growth-restricted infant at Monash Health during January 2013-July 2015. Unadjusted and adjusted analyses were undertaken to examine the association between the mother being of likely refugee background and severe FGR in singletons delivered after 40 weeks. RESULTS: There was an association between the mother being of likely refugee background and giving birth to a severely growth-restricted baby after 40 weeks with these mothers at two and half times the odds compared to mothers of non-refugee background (adjusted odds ratio 2.52; 95% confidence interval: 1.44-4.42). CONCLUSIONS: While detecting FGR is clinically challenging, our findings suggest that maternity services need to be supported to offer care tailored to the specific needs of vulnerable and disadvantaged populations. Providing quality, culturally responsive and accessible care is fundamental to addressing refugee maternal and perinatal health inequalities.

Bridging the language gap: a co-designed quality improvement project to engage professional interpreters for women during labour.

Objective The aim of the study was to improve the engagement of professional interpreters for women during labour. Methods The quality improvement initiative was co-designed by a multidisciplinary group at one Melbourne hospital and implemented in the birth suite using the plan-do-study-act framework. The initiative of offering women an interpreter early in labour was modified over cycles of implementation and scaled up based on feedback from midwives and language services data. Results The engagement of interpreters for women identified as requiring one increased from 28% (21/74) at baseline to 62% (45/72) at the 9th month of implementation. Conclusion Improving interpreter use in high-intensity hospital birth suites is possible with supportive leadership, multidisciplinary co-design and within a framework of quality improvement cycles of change. What is known about the topic? Despite Australian healthcare standards and policies stipulating the use of accredited interpreters where needed, studies indicate that services fall well short of meeting these during critical stages of childbirth. What does the paper add? Collaborative approaches to quality improvement in hospitals can significantly improve the engagement of interpreters to facilitate communication between health professionals and women with low English proficiency. What are the implications for practice? This language services initiative has potential for replication in services committed to improving effective communication between health professionals and patients.

Single-room usage patterns and allocation decision-making in an Australian public hospital: a sequential exploratory study.

AIMS AND OBJECTIVES: The aims are to (1) measure occupancy rates of single and shared rooms; (2) compare single room usage patterns and (3) explore the practice, rationale and decision-making processes associated with single rooms; across one Australian public health service. BACKGROUND: There is a tendency in Australia and internationally to increase the proportion of single patient rooms in hospitals. To date there have been no Australian studies that investigate the use of single rooms in clinical practice. DESIGN: This study used a sequential exploratory design with data collected in 2014. METHODS: A descriptive survey was used to measure the use of single rooms across a two-week time frame. Semi-structured interviews were undertaken with occupancy decision-makers to explore the practices, rationale decision-making process associated with single-room allocation. RESULTS: Total bed occupancy did not fall below 99·4% during the period of data collection. Infection control was the primary reason for patients to be allocated to a single room, however, the patterns varied according to ward type and single-room availability. For occupancy decision-makers, decisions about patient allocation was a complex and challenging process, influenced and complicated by numerous factors including occupancy rates, the infection status of the patient/s, funding and patient/family preference. Bed moves were common resulting from frequent re-evaluation of need. CONCLUSION: Apart from infection control mandates, there was little tangible evidence to guide decision-making about single-room allocation. Further work is necessary to assist nurses in their decision-making. RELEVANCE TO CLINICAL PRACTICE: There is a trend towards increasing the proportion of single rooms in new hospital builds. Coupled with the competing clinical demands for single room care, this study highlights the complexity of nursing decision-making about patient allocation to single rooms, an issue urgently requiring further attention.

Continuity of care by a primary midwife (caseload midwifery) increases women's satisfaction with antenatal, intrapartum and postpartum care: results from the COSMOS randomised controlled trial.

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).

Quality of prenatal care questionnaire: psychometric testing in an Australia population.

BACKGROUND: The quality of antenatal care is recognized as critical to the effectiveness of care in optimizing maternal and child health outcomes. However, research has been hindered by the lack of a theoretically-grounded and psychometrically sound instrument to assess the quality of antenatal care. In response to this need, the 46-item Quality of Prenatal Care Questionnaire (QPCQ) was developed and tested in a Canadian context. The objective of this study was to validate the QPCQ and to establish its internal consistency reliability in an Australian population. METHODS: Study participants were recruited from two public maternity services in two Australian states: Monash Health, Victoria and Wollongong Hospital, New South Wales. Women were eligible to participate if they had given birth to a single live infant, were 18 years or older, had at least three antenatal visits during the pregnancy, and could speak, read and write English. Study questionnaires were completed in hospital. A confirmatory factor analysis (CFA) was conducted. Construct validity, including convergent validity, was further assessed against existing questionnaires: the Patient Expectations and Satisfaction with Prenatal Care (PESPC) and the Prenatal Interpersonal Processes of Care (PIPC). Internal consistency reliability of the QPCQ and each of its six subscales was assessed using Cronbach's alpha. RESULTS: Two hundred and ninety-nine women participated in the study. CFA verified and confirmed the six factors (subscales) of the QPCQ. A hypothesis-testing approach and an assessment of convergent validity further supported construct validity of the instrument. The QPCQ had acceptable internal consistency reliability (Cronbach's alpha = 0.97), as did each of the six factors (Cronbach's alpha = 0.74 to 0.95). CONCLUSIONS: The QPCQ is a valid and reliable self-report measure of antenatal care quality. This instrument fills a scientific gap and can be used in research to examine relationships between the quality of antenatal care and outcomes of interest, and to examine variations in antenatal care quality. It also will be useful in quality assurance and improvement initiatives.

Who is holding the baby? Women's experiences of contact with their baby immediately after birth: An Australian population-based survey.

BACKGROUND: Seeing and holding their baby immediately after the birth is the pinnacle of the childbearing process for parents. Few studies have examined women's experiences of seeing and holding their baby immediately after birth. We investigated women's experiences of initial contact with their newborns using data from an Australian population-based survey. METHODS: All women who gave birth in September/October in 2007 in two Australian states were mailed questionnaires six months following the birth. Women were asked three questions about early newborn contact including where their baby was held in the first hour after birth and whether they were able to hold their baby as soon and for as long as they liked. We examined the association between model of maternity care and early newborn contact stratified by admission to SCN/NICU. RESULTS: The majority (92%) of women whose babies remained with them reported holding their babies as soon and for as long as they liked in the first hour after birth. However, for women whose babies were admitted to SCN/NICU only a minority (47%) reported this. Women in public models of care (with the exception of primary midwifery care) whose babies remained with them were less likely to report holding their babies as soon and for as long as they liked compared to women in private care. CONCLUSION: Our findings suggest that there is potential to increase the proportion of mothers and fathers who get to hold their baby immediately after the birth by modifying birth suite and operating room practices.

Bridging the Gap: using an interrupted time series design to evaluate systems reform addressing refugee maternal and child health inequalities.

BACKGROUND: The risk of poor maternal and perinatal outcomes in high-income countries such as Australia is greatest for those experiencing extreme social and economic disadvantage. Australian data show that women of refugee background have higher rates of stillbirth, fetal death in utero and perinatal mortality compared with Australian born women. Policy and health system responses to such inequities have been slow and poorly integrated. This protocol describes an innovative programme of quality improvement and reform in publically funded universal health services in Melbourne, Australia, that aims to address refugee maternal and child health inequalities. METHODS/DESIGN: A partnership of 11 organisations spanning health services, government and research is working to achieve change in the way that maternity and early childhood health services support families of refugee background. The aims of the programme are to improve access to universal health care for families of refugee background and build organisational and system capacity to address modifiable risk factors for poor maternal and child health outcomes. Quality improvement initiatives are iterative, co-designed by partners and implemented using the Plan Do Study Act framework in four maternity hospitals and two local government maternal and child health services. Bridging the Gap is designed as a multi-phase, quasi-experimental study. Evaluation methods include use of interrupted time series design to examine health service use and maternal and child health outcomes over a 3-year period of implementation. Process measures will examine refugee families' experiences of specific initiatives and service providers' views and experiences of innovation and change. DISCUSSION: It is envisaged that the Bridging the Gap program will provide essential evidence to support service and policy innovation and knowledge about what it takes to implement sustainable improvements in the way that health services support vulnerable populations, within the constraints of existing resources.

Midwives' and doctors' perceptions of their preparation for and practice in managing the perineum in the second stage of labour: a cross-sectional survey.

OBJECTIVE: to identify the perceptions of midwives and doctors at Monash Women's regarding their educational preparation and practices used for perineal management during the second stage of labour. DESIGN: anonymous cross-sectional semi-structured questionnaire ('The survey'). SETTING: the three maternity hospitals that form Monash Women's Maternity Services, Monash Health, Victoria, Australia. PARTICIPANTS: midwives and doctors attending births at one or more of the three Monash Women's maternity hospitals. METHODS: a semi-structured questionnaire was developed, drawing on key concepts from experts and peer-reviewed literature. FINDINGS: surveys were returned by 17 doctors and 69 midwives (37% response rate, from the 230 surveys sent). Midwives and doctors described a number of techniques they would use to reduce the risk of perineal trauma, for example, hands on the fetal head/perineum (11.8% of doctors, 61% of midwives), the use of warm compresses (45% of midwives) and maternal education and guidance with pushing (49.3% of midwives). When presented with a series of specific obstetric situations, respondents indicated that they would variably practice hands on the perineum during second stage labour, hands off and episiotomy. The majority of respondents indicated that they agreed or strongly agreed that an episiotomy should sometimes be performed (midwives 97%, doctors 100%). All the doctors had training in diagnosing severe perineal trauma involving anal sphincter injury (ASI), with 77% noting that they felt very confident with this. By contrast, 71% of the midwives reported that they had received training in diagnosing ASI and only 16% of these reported that they were very confident in this diagnosis. All doctors were trained in perineal repair, compared with 65% of midwives. Doctors were more likely to indicate that they were very confident in perineal repair (88%) than the midwives (44%). Most respondents were not familiar with the rates of perineal trauma either within their workplace or across Australia. KEY CONCLUSIONS: Midwives and doctors indicated that they would use the hands on or hands off approach or episiotomy depending on the specific clinical scenario and described a range of techniques that they would use in their overall approach to minimising perineal trauma during birth. Midwives were more likely than doctors to indicate their lack of training and/or confidence in conducting perineal repair and diagnosing ASI. IMPLICATIONS FOR PRACTICE: many midwives indicated that they had not received training in diagnosing ASI, perineal repair and midwives' and doctors' knowledge of the prevalence of perineal outcomes was poor. Given the importance of these skills to women cared for by midwives and doctors, the findings may be used to inform the development of quality improvement activities, including training programs and opportunities for gaining experience and expertise with perineal management. The use of episiotomy and hands on/hands off the perineum in the survey scenarios provides reassurance that doctors and midwives take a number of factors into account in their clinical practice, rather than a preference for one or more interventions over others.

Maternal Asian ethnicity and the risk of anal sphincter injury.

OBJECTIVE: To examine associations between maternal Asian ethnicity (South Asian and South East/East Asian) and anal sphincter injury. DESIGN: Retrospective cross-sectional study, comparing outcomes for Asian women with those of Australian and New Zealand women. SETTING: A large metropolitan maternity service in Victoria, Australia. POPULATION: Australian/New Zealand, South Asian and South East/East Asian women who had a singleton vaginal birth from 2006 to 2012. METHODS: The relation between maternal ethnicity and anal sphincter injury was assessed by logistic regression, adjusting for potential confounders. MAIN OUTCOME MEASURES: Anal sphincter injury was defined as a third or fourth degree tear (with or without episiotomy). RESULTS: Among 32,653 vaginal births there was a significant difference in the rate of anal sphincter injury by maternal region of birth (p < 0.001). After adjustment for confounders, nulliparous women born in South Asian and South East/East Asia were 2.6 (95% confidence interval 2.2-3.3; p < 0.001) and 2.1 (95% confidence interval 1.7-2.5; p < 0.001) times more likely to sustain an anal sphincter injury than Australian/New Zealand women, respectively. Parous women born in South Asian and South East/East Asia were 2.4 (95% confidence interval 1.8-3.2; p < 0.001) and 2.0 (95% confidence interval 1.5-2.7; p < 0.001) times more likely to sustain an anal sphincter injury than Australian/New Zealand women, respectively. CONCLUSION: There are ethnic differences in the rates of anal sphincter injury not fully explained by known risk factors for such trauma. This may have implications for care provision.

Why are young women less likely to breastfeed? Evidence from an Australian population-based survey.

BACKGROUND: Younger mothers are less likely to continue breastfeeding compared with older mothers. However, few studies have explored this finding. The aim of this study was to investigate breastfeeding initiation and duration among women aged under 25 and 25 years or older, and assess the extent to which any differences associated with maternal age were explained by other factors. METHODS: All women who gave birth in September and October 2007 in two Australian states were mailed questionnaires 6 months after the birth. Women were asked about infant feeding, maternity care experiences, sociodemographic characteristics, and exposure to stressful life events and social health issues. We examined the association between maternal age, breastfeeding initiation, and breastfeeding at 6 months, while adjusting for a range of social and obstetric risk factors. RESULTS: While younger women were just as likely to initiate breastfeeding as older women (AdjOR 1.13; 95% CI 0.63-2.05), they had almost twice the odds of not breastfeeding at 6 months (AdjOR 1.76; 95% CI 1.34-2.33). Several psychosocial factors may explain why young women are less likely to breastfeed for longer periods. CONCLUSIONS: Given the complexity of young childbearing women's lives, supporting them to breastfeed will require a multisectorial approach that addresses social disadvantage and resulting health inequalities.

How effectively do midwives manage the care of obese pregnant women? A cross-sectional survey of Australian midwives.

BACKGROUND: Obesity and overweight are common issues for pregnant women and their healthcare providers. Obesity in pregnancy is associated with poorer maternal and perinatal outcomes and presents particular challenges in day-to-day clinical practice. QUESTION: The aim of this study was to examine midwifery clinical practice for obese pregnant women. METHODS: We conducted a cross-sectional survey of midwives using an on-line survey distributed to members of the Australian College of Midwives. Midwives were asked about: the extent to which they provided evidence-based care; their use of a clinical guideline; their education and training and confidence to counsel obese pregnant women. Data for the questions about knowledge, clinical practice and views of education and training were summarized using descriptive statistics. Unadjusted analyses were undertaken to examine the association between use of a guideline and provision of evidence-based care and ratings of education, training and counselling. RESULTS: The survey highlighted considerable variations in practice in the care and management of obese pregnant women. Respondents' clinical knowledge and their views about education and training and counselling skills highlighted some deficits. Those using a clinical guideline were more likely to report that they 'always': tell the woman she is overweight or obese (OR 3.5; 95% CI: 1.9, 6.4); recommend a higher dose of folic acid (OR 4.6; 95% CI: 1.9, 6.4); refer to an obstetrician (OR 2.9; 95% CI: 1.2, 3.4); prepare a pregnancy plan (OR 2.0; 95% CI: 1.2, 3.3) and plan to obtain an anaesthetic referral (OR 2.6; 95% CI: 1.5, 4.3). They were also more likely to report adequate/comprehensive education and training and greater confidence to counsel obese pregnant women. CONCLUSIONS: Registered midwives need continuing professional development in communication and counselling to more effectively manage the care of obese pregnant women. The universal use of a clinical guideline may have a positive impact by helping midwives to base early care decisions on clinical evidence.

Undergraduate midwifery students' sense of belongingness in clinical practice.

BACKGROUND: Clinical placements form a large and integral part of midwifery education. While much has been written about nursing students' clinical placements, less is known about clinical experiences of undergraduate midwifery students. In nursing, belongingness has been demonstrated to be a key factor in clinical learning but little is known about this in midwifery education. OBJECTIVES: This study sought to examine undergraduate midwifery students' sense of belongingness in their clinical practice. DESIGN: A quantitative design using an online questionnaire was employed. A tool adapted by Levett-Jones (2009a), and previously used with nursing students, was utilised to examine sense of belonging in undergraduate midwifery students. PARTICIPANTS: Sixty undergraduate midwifery students from two campuses at one Australian university participated in the study. Students were drawn from a single Bachelor of Midwifery degree and a double Bachelor of Nursing/Bachelor of Midwifery degree. METHODS: On completion of a scheduled lecture, students were invited by one of the researchers to participate in the study by completing the online questionnaire and the link provided. Data were analysed using descriptive statistics. RESULTS: Midwifery students generally reported similar perceptions of belongingness with previous studies on nursing students. However, a few differences were noted that require further exploration to fully understand. CONCLUSIONS: Midwifery students experienced a sense of belonging in their clinical placements. The findings contribute to understandings of the experiences for midwifery students and provide a foundation on which to develop future clinical placement experiences.

Women's experience of domiciliary postnatal care in Victoria and South Australia: a population-based survey.

OBJECTIVE: Despite the expansion of postnatal domiciliary services, we know little about the women receiving visits and how they regard their care. The aim of this study is to examine the provision of postnatal domiciliary care from a consumer perspective. METHODS: All women who gave birth in September-October 2007 in South Australia and Victoria were mailed questionnaires 6 months after the birth. Women were asked if they had received a midwifery home visit, and to rate the care they received. RESULTS: More women in South Australia reported receiving a domiciliary visit than in Victoria (88.0% v. 76.0%) and they were more likely to rate their care as 'very good' (69.1% v. 63.4%). Younger women, women on a lower income, who were holding a healthcare concession card or who had not completed secondary education were less likely to receive a visit. CONCLUSION: Although the majority of women in public maternity care in Victoria and South Australia receive domiciliary care and rate it positively, there are significant state-based differences. Those more likely to benefit from domiciliary care are less likely to receive a visit. There is a need to further explore the purpose, aims and content of domiciliary care at individual and state-wide levels.

Advanced maternal age and obstetric morbidity for women giving birth in Victoria, Australia: A population-based study.

BACKGROUND: As the proportions of older women giving birth increase, there is a growing body of evidence on the increased risks of poorer maternal and perinatal outcomes for this group. However, the associations are not completely understood. This study aimed to establish the prevalence of selected maternal morbidities and examine whether advanced maternal age is associated with a higher risk of morbidity for women giving birth in Victoria. METHOD: Data on all births over 20 weeks‧ gestation for 2005 and 2006 were obtained from the Victorian Perinatal Data Collection. Unadjusted and adjusted analyses were undertaken using logistic regression to examine and quantify the association between advanced maternal age (35 years and older) and selected obstetric morbidities and complications. RESULTS: There was evidence of an association between older maternal age and selected morbidities and complications. Older nulliparous women were at highest odds of gestational diabetes (AdjOR, 1.83; 95% CI, 1.67-2.02), placenta praevia (AdjOR, 2.02; 95% CI, 1.68-2.44), multiple birth (AdjOR, 1.80; 95% CI, 1.58-2.06) and caesarean delivery (AdjOR, 1.93; 95% CI, 1.84-2.02). Older multiparous women were at highest odds of gestational diabetes (AdjOR, 2.01; 95% CI, 1.88-2.15) and placenta praevia (AdjOR, 2.11; 95% CI, 1.83-2.44). CONCLUSIONS: Older women giving birth in Victoria are at an increased risk of a range of obstetric morbidities. Delayed childbearing for an increasing number of women has societal and public health ramifications and will potentially place greater demand on healthcare services.

Managing women with acute physiological deterioration: student midwives performance in a simulated setting.

OBJECTIVE: Midwives' ability to manage maternal deterioration and 'failure to rescue' are of concern with questions over knowledge, clinical skills and the implications for maternal morbidity and, mortality rates. In a simulated setting our objective was to assess student midwives' ability to assess, and manage maternal deterioration using measures of knowledge, situation awareness and skill, performance. METHODS: An exploratory quantitative analysis of student performance based upon performance, ratings derived from knowledge tests and observational ratings. During 2010 thirty-five student, midwives attended a simulation laboratory completing a knowledge questionnaire and two video, recorded simulated scenarios. Patient actresses wearing a 'birthing suit' simulated deteriorating, women with post-partum and ante-partum haemorrhage (PPH and APH). Situation awareness was, measured at the end of each scenario. Applicable descriptive and inferential statistical tests were, applied to the data. FINDINGS: The mean total knowledge score was 75% (range 46-91%) with low skill performance, means for both scenarios 54% (range 39-70%). There was no difference in performance between the scenarios, however performance of key observations decreased as the women deteriorated; with significant reductions in key vital signs such as blood pressure and blood loss measurements. Situation, awareness scores were also low (54%) with awareness decreasing significantly (t(32)=2.247, p=0.032), in the second and more difficult APH scenario. CONCLUSION: Whilst knowledge levels were generally good, skills were generally poor and decreased as the women deteriorated. Such failures to apply knowledge in emergency stressful situations may be resolved by repetitive high stakes and high fidelity simulation.

Maternal age, ethnicity and gestational diabetes mellitus.

BACKGROUND: in Australia, and globally, rates for gestational diabetes mellitus (GDM) have risen dramatically in recent decades. This is of concern as GDM is associated with adverse pregnancy outcomes and additional health-care costs. Factors linked to increasing incidence include older maternal age and non-Caucasian ethnicity. However, as yet, there is no clear consensus on the magnitude of effect associated with these factors in combination. This study therefore investigated the effect of maternal age and country/region of birth on GDM incidence. METHODS: all women who gave birth in Victoria, Australia in 2005 and 2006 (n=133,359) were included in this population-based cross-sectional study. Stratified cross-tabulations were conducted to examine the incidence of GDM by maternal age group and country/region of birth. Primiparous women were further analysed separately from parous women. The proportion of women with GDM was reported, along with the χ(2) for linear trend. FINDINGS: whilst women born outside Australia constituted just 24.6% of women giving birth during the study period, they accounted for 41.4% of GDM cases. The highest GDM incidence was seen among Asian women at 11.5%, compared with Australian born women at 3.7%. There was strong evidence that women born in all regions except North America were increasingly likely to develop GDM in pregnancies at older ages (p<0.001).On examining age related GDM trends by maternal region of birth, higher rates were seen across all regions studied but were most marked among women born in Asia and the Middle East. CONCLUSIONS: older maternal age and non-Australian birth increased a woman's risk of developing GDM and this increase was most evident among Asian women. As GDM is associated with adverse maternal and infant outcomes, it is important to explore ways of preventing GDM, and to put in place strategies to effectively manage GDM during pregnancy and to reduce the later risk of developing type 2 diabetes. Pregnancy presents midwives with a unique opportunity to provide education and to encourage dietary and behavioural modifications as women have repeated contact with the health system during this time.