Alternatives to low birthweight as a population-level indicator of infant and child health.

BACKGROUND: Low birthweight (<2500 g) is often used as a population-level indicator of maternal-child health, as it is easy to measure and correlates with poorer infant health outcomes. However, it conflates preterm birth and intrauterine growth restriction, which have different causal pathways and require different approaches to prevention. Small for gestational age (SGA) (a proxy for growth restriction) and preterm birth may be more informative measures. We evaluated low birthweight as a population-level indicator. METHODS: We conducted a population-based cohort study of singleton live births in New South Wales (NSW), Australia, using linked data from 1994-2006 birth, hospital, death and educational records, with follow-up until 2014. Outcomes of babies born of low birthweight, preterm and SGA were compared with well-grown term infants (i.e. not low birthweight or SGA). Overlap between groups and temporal trends were also examined. RESULTS: Of 1 093 765 singleton live births, 47 946 (4.4%) infants were low birthweight and had poorer outcomes than well-grown term infants (2.7% vs. 0.1% infant mortality; 13% vs. 6% below national minimum numeracy standard). SGA and preterm infants also had poorer outcomes (0.5%, 2.3% infant mortality respectively; 10%, 11% below numeracy standard) but 80% of SGA and 47% of preterm infants were not low birthweight. For all outcomes, low birthweight identified a smaller proportion of infants with poor outcomes than preterm birth and than either SGA or low birthweight at term. The proportion of low-birthweight births remained constant over time, while the proportion of births that were preterm increased and proportion of SGA decreased. CONCLUSIONS: Low birthweight, SGA and preterm infants are all at higher risk of poorer outcomes but low birthweight inadequately captures, and masks trends in, both preterm births and births that are SGA. Reporting preterm births and an indicator of growth restriction at term will identify vulnerable groups better than using the measure of low birthweight.

Knowledge, experience and attitudes towards skin-to-skin contact following Caesarean sections among health professionals in Vietnam.

AIM: This study explored knowledge, experience and attitudes of health professionals towards early essential newborn care and skin-to-skin contact following Caesarean sections in a tertiary hospital in Central Vietnam. METHOD: We conducted a cross-sectional descriptive study using an anonymous questionnaire in March 2016. Health professionals from obstetrics, anaesthesiology and neonatology departments were surveyed. RESULTS: All of the 204 surveys were returned, accounting for 82% of total staff involved in the care for women and newborns with Caesarean sections. Correct knowledge of early essential newborn care was lowest among anaesthesiology staff. Health professionals reported that ≥90% of Caesarean section births they attended in the preceding week had skin-to-skin contact. Approximately 16% obstetricians, 71% midwives, 49% anaesthesiology and 76% neonatology staff considered the current frequency of skin-to-skin contact to be about right. The remainder considered the current rate too high. All professional groups identified the main difficulties of conducting skin-to-skin contact as the temperature in the operating theatre and the need for additional staff. Other concerns included increasing the risk of the baby of falling off, prolonging the operation and difficulty to monitor mothers. CONCLUSION: The study identifies issues where improvements can be made in the implementation of skin-to-skin contact following Caesarean sections.

Pediatric admissions that include intensive care: a population-based study.

BACKGROUND: Pediatric admissions to intensive care outside children's hospitals are generally excluded from registry-based studies. This study compares pediatric admission to specialist pediatric intensive care units (PICU) with pediatric admissions to intensive care units (ICU) in general hospitals in an Australian population. METHODS: We undertook a population-based record linkage cohort study utilizing longitudinally-linked hospital and death data for pediatric hospitalization from New South Wales, Australia, 2010-2013. The study population included all new pediatric, post-neonatal hospital admissions that included time in ICU (excluding neonatal ICU). RESULTS: Of 498,466 pediatric hospitalizations, 7525 (1.5%) included time in an intensive care unit - 93.7% to PICU and 6.3% to ICU in a general (non-PICU) hospital. Non-PICU admissions were of older children, in rural areas, with shorter stays in ICU, more likely admitted for acute conditions such as asthma, injury or diabetes, and less likely to have chronic conditions, receive continuous ventilatory support, blood transfusion, parenteral nutrition or die. CONCLUSIONS: A substantial proportion of children are admitted to ICUs in general hospitals. A comprehensive overview of pediatric ICU admissions includes these admissions and the context of the total hospitalization.

Factors associated with breastfeeding intent among mothers of newborn babies in Da Nang, Viet Nam.

BACKGROUND: Breastfeeding is recognized as the single most cost-effective intervention to reduce child morbidity and mortality. However, few studies have explored perceived barriers to breastfeeding and factors associated with breastfeeding intent among mothers of newborn babies in Viet Nam. We conducted a study to assess breastfeeding initiation rates, intent to breastfeed exclusively for 6 months or more and perceived barriers to breastfeed among mothers of newborn babies in Da Nang, Viet Nam. METHODS: We conducted a cross-sectional questionnaire survey of mothers in the postnatal wards of Da Nang Hospital for Women and Children in central Viet Nam from 10 February 2017 to 24 February 2017, following implementation of the World Health Organization (WHO) Essential Newborn Care (ENC) package. RESULTS: Of 286 mothers surveyed, 259 (90.6%) initiated breastfeeding; 203/258 (78.7%) within 1 hour (h) of birth. Most (207, 72.4%) mothers indicated intent to breastfeed exclusively for 6 months or more, but this was lower among mothers of preterm babies (82.2% versus 20.0%, p < 0.001) and those without post-secondary school education (74.8% versus 55.6%, p = 0.02). Amongst mothers struggling to establish breastfeeding, 18/27 (66.7%) had a Cesarean section. Planned non-exclusive breastfeeding was mostly (39, 60.9%) motivated by mothers' concern that their milk supply would be insufficient for their baby's growth requirements. Most mothers had good knowledge about the benefits of breastfeeding and indicated strong decision autonomy. CONCLUSIONS: We documented high rates of early breastfeeding establishment and intent to breastfeed exclusively for 6 months or more. This probably reflects high levels of maternal education and successful implementation of the WHO ENC package. Mothers of premature babies may benefit from additional support.

Contribution of maternal age, medical and obstetric history to maternal and perinatal morbidity/mortality for women aged 35 or older.

BACKGROUND: As age is not modifiable, pregnancy risk information based on age alone is unhelpful for older women. AIM: To determine severe morbidity/mortality rates for women aged ≥35 years according to maternal profile based on parity, pre-existing medical conditions and prior pregnancy complications, and to assess the independent contribution of age. MATERIALS AND METHODS: Population-based record-linkage study using NSW hospitalisation and birth records 2006-2012. Maternal and perinatal mortality/morbidity were assessed for non-anomalous singleton births to women aged ≥35 years. RESULTS: For 117 357 pregnancies among 99 375 women aged ≥35 years, the median age at delivery was 37 years (range 35-56 years), including: 35 652 (30.4%) multiparae without pre-existing medical or obstetric complications, 33,058 (28.2%) nulliparae without pre-existing medical conditions and 30 325 (25.8%) multiparae with prior pregnancy complications. Maternal and perinatal mortality/morbidity varied by maternal profile with ranges of 0.9-3.5% and 2.4-11.9%, respectively. For nulliparae, each five-year increase in age did not contribute significantly to maternal risk after controlling for medical conditions (adjustedodds ratio 1.08, 95% CI 0.93-1.25), but did confer perinatal risk (1.14; 1.05-1.25). For multiparae, each five-year increase in age beyond 35 years was independently associated with adverse maternal (1.23; 1.09-1.39) and perinatal outcomes (1.23; 1.09-1.39). CONCLUSIONS: For women aged ≥35 years, presence of medical conditions conferred a greater risk for morbidity/mortality than age itself. For multiparous women, the effects of medical and obstetric history were additive. The contribution of maternal age to adverse outcomes in pregnancies without significant medical and obstetric history is modest.

Educational outcomes for children with cerebral palsy: a linked data cohort study.

AIM: To identify a cohort of children with cerebral palsy (CP) from hospital data; determine the proportion that participated in standardized educational testing and attained a score within the normal range; and describe the relationship between test results and motor symptoms. METHOD: This population-based retrospective cohort study used data from New South Wales, Australia. We linked hospital data for children younger than 16 years of age admitted between 1st July 2000 and 31st March 2014 to education data from 2009 to 2014. Hospital diagnosis codes were used to identify a cohort of children with CP (n=3944) and describe their motor symptoms. Educational outcomes in the CP cohort were compared with those among children without CP. RESULTS: Of those with educational data (n=1770), 46% were exempt from reading assessment because of intellectual or functional disability, 7% were absent or withdrawn from testing and 47% participated in testing. About 30% of all children with educational data had test scores in the normal range. The proportion was greatest among those with hemiplegia (>40%) and lowest among those with tetraplegia (<10%). INTERPRETATION: One-third of children with CP participated in standardized testing and achieved a result in the normal range. The proportions were lower in children with more severe motor symptoms. WHAT THIS PAPER ADDS: From 2009 to 2014, most Australian children with cerebral palsy (CP) attended a mainstream school. The rate of disability-related exemption from standardized educational testing was almost 50%. Thirty per cent of children with CP achieved educational scores in the normal range.

Childhood Health and Educational Outcomes Associated With Maternal Sleep Apnea: A Population Record-Linkage Study.

Objectives: Sleep apnea in pregnancy is known to adversely affect birth outcomes. Whether in utero exposure to maternal sleep apnea is associated with long-term childhood consequences is unclear. Methods: Population-based longitudinal study of singleton infants born during 2002-2012 was conducted using linked birth, hospital, death, developmental, and educational records from New South Wales, Australia. Maternal sleep apnea during pregnancy was identified from hospital records. Outcomes were mortality and hospitalizations up to age 6, developmental vulnerability in the first year of school (aged 5-6 years), and performance on standardized tests in the third year of school (aged 7-9 years). Cox proportional hazards and modified Poisson regression models were used to calculate hazard and risk ratios for outcomes in children exposed to maternal apnea compared with those not exposed. Results: Two hundred nine of 626188 singleton infants were exposed to maternal sleep apnea. Maternal apnea was not significantly associated with mortality (Fisher's exact p = .48), developmental vulnerability (adjusted RR 1.29; 95% CI 0.75-2.21), special needs status (1.58; 0.61-4.07), or low numeracy test scores (1.03; 0.63-1.67) but was associated with low reading test scores (1.55; 1.08-2.23). Maternal apnea significantly increased hospitalizations in the first year of life (adjusted HR 1.81; 95% CI 1.40-2.34) and between the first and sixth birthdays (1.41; 1.14-1.75). This is partly due to admissions for suspected pediatric sleep apnea. Conclusions: Maternal sleep apnea during pregnancy is associated with poorer childhood health. Its impact on developmental and cognitive outcomes warrants further investigation.

Perineal length among Vietnamese women.

OBJECTIVE: Vietnamese clinicians routinely perform episiotomies in the belief that 3rd-4th degree tears may be prevented, based partly on the view that Vietnamese women have a short perineal length that puts them at increased risk of tears. However, there is no evidence to suggest Vietnamese women have a short perineum compared with other populations. We aimed to determine the mean perineal length among Vietnamese women in early labor and in the second stage, and to compare this to findings from similar studies in other populations. MATERIALS AND METHODS: We undertook an observational study in a tertiary obstetric hospital in Vietnam from October 2014 to June 2015. Pregnant women who presented in early labor with a live singleton cephalic presentation at ≥37 weeks gestation were eligible. Perineal length was measured early in the 1st stage of labor (≤4 cm dilation) and in 2nd stage of labor (10 cm dilation). Mean perineal length was compared to other populations using t-tests. RESULTS: Of 395 women, 159 (40.3%) were nulliparous and 236 (59.8%) multiparous. Overall the mean perineal length in early labor was 3.4 cm (±0.4), and did not differ by parity. Mean perineal length among Vietnamese women was significantly shorter (P < 0.001) than other populations (means 3.8-4.6 cm). Among 365 women who reached 2nd stage the mean perineal length was 4.3 cm (±0.6). CONCLUSION: The perception that Vietnamese women have a relatively shorter perineal length appears to have some basis and outcomes reported from episiotomy trials may not be generalizable to Vietnamese women.

Long-term outcomes for large for gestational age infants born at term.

AIM: Large for gestational age (LGA) babies have increased risks for short-term outcomes such as shoulder dystocia, neonatal hypoglycaemia and longer hospital stay. Little is known of long-term health, development and educational outcomes of LGA babies. The aim of this study was to determine the long-term health, mortality, development and educational outcomes for infants born LGA at term. METHODS: A population-based record linkage study of live singletons born at term (37-41 weeks of gestation) in New South Wales, Australia, from 2001 to 2006. RESULTS: This study compared 49 439 LGA (>90th percentile for birthweight, gestational age and sex) and 400 418 appropriate size for gestational age (AGA; 10th-90th percentile) infants. LGA infants had increased risk of birth and neonatal outcomes and hospitalisations, for brachial plexus injury after the neonatal period, and for all causes from 1 to 5 years of age. There were no differences in mortality up to 5 years of age or hospitalisations for type 1 diabetes in childhood. LGA infants had lower rates of developmental vulnerability (in kindergarten) and showed a significant trend (χ2 for trend <0.0001) to fewer low scores and more high scores in reading and numeracy (in Year 3) compared with AGA. After adjusting for potential confounders, only the relative risk for higher reading scores was statistically significant. CONCLUSIONS: LGA infants show positive long-term health, development and educational outcomes. Concerns for LGA infants still remain in the perinatal period as a result of birth trauma; however, these complications usually do not persist in postnatal and early childhood.

Variation in clinical decision-making for induction of labour: a qualitative study.

BACKGROUND: Unexplained variation in induction of labour (IOL) rates exist between hospitals, even after accounting for casemix and hospital differences. We aimed to explore factors that influence clinical decision-making for IOL that may be contributing to the variation in IOL rates between hospitals. METHODS: We undertook a qualitative study involving semi-structured, audio-recorded interviews with obstetricians and midwives. Using purposive sampling, participants known to have diverse opinions on IOL were selected from ten Australian maternity hospitals (based on differences in hospital IOL rate, size, location and case-mix complexities). Transcripts were indexed, coded, and analysed using the Framework Approach to identify main themes and subthemes. RESULTS: Forty-five participants were interviewed (21 midwives, 24 obstetric medical staff). Variations in decision-making for IOL were based on the obstetrician's perception of medical risk in the pregnancy (influenced by the obstetrician's personality and knowledge), their care relationship with the woman, how they involved the woman in decision-making, and resource availability. The role of a 'gatekeeper' in the procedural aspects of arranging an IOL also influenced decision-making. There was wide variation in the clinical decision-making practices of obstetricians and less accountability for decision-making in hospitals with a high IOL rate, with the converse occurring in hospitals with low IOL rates. CONCLUSION: Improved communication, standardised risk assessment and accountability for IOL offer potential for reducing variation in hospital IOL rates.

Uptake of external cephalic version for term breech presentation: an Australian population study, 2002-2012.

BACKGROUND: The safety, efficacy, and cost-effectiveness of external cephalic version (ECV) for term breech presentation has been demonstrated. Clinical guidelines recommend ECV for all eligible women, but the uptake of this procedure in the Australian healthcare setting is unknown. This study aimed to describe ECV uptake in New South Wales, the most populous state of Australia, during 2002 to 2012. METHODS: Data from routine hospital and birth records were used to identify ECVs conducted at ≥36 weeks' gestation. Women with ECV were compared to women who were potentially eligible for but did not have ECV. Eligibility for ECV was based on clinical guidelines. For those with ECV, birth outcomes following successful and unsuccessful procedures were examined. RESULTS: In N = 32,321 singleton breech pregnancies, 10.5% had ECV, 22.3% were ineligible, and 67.2% were potentially eligible but did not undergo ECV. Compared to women who were eligible but who did not attempt ECV, those who had ECV were more likely to be older, multiparous, overseas-born, public patients at delivery, and to deliver in tertiary hospitals in urban areas (p < 0.01). Fewer women who underwent ECV smoked during pregnancy, fewer were morbidly obese, and fewer had a hypertensive disorder of pregnancy, compared to those who were eligible. Caesarean section occurred in 25.9% of successful compared to 95.6% of unsuccessful ECVs. Infant outcomes did not differ by ECV success. CONCLUSIONS: The majority of women with a breech presentation did not receive ECV. It is unclear whether this is attributable to issues with service provision or low acceptability among women. Policies to improve access to and information about ECV appear necessary to improve uptake among women with term breech presentation. Improved data collection around the diagnosis of breech presentation, ECV attempts, and outcomes may help to identify specific barriers to ECV uptake.

Cervical cerclage placed before 14 weeks gestation in women with one previous midtrimester loss: A population-based cohort study.

BACKGROUND: Cervical cerclage is used in an attempt to reduce recurrence risk of preterm birth, but evidence for use is limited. AIMS: To compare pregnancy outcomes among women with a single previous midtrimester delivery when managed with or without a cervical cerclage. MATERIALS AND METHODS: Population-based cohort study of all women in New South Wales, Australia with a singleton pregnancy ending in birth/miscarriage ≥14 and <28 weeks, between 2003 and 2011. Modified Poisson regression was used to compare outcomes in the next subsequent pregnancy, for women with a cerclage inserted <14 weeks, and those without cerclage. The primary outcome was gestational age <37 weeks at birth/miscarriage in the next pregnancy. Secondary outcomes included: maternal morbidity, preterm prelabour rupture of membranes (PPROM), stillbirth/neonatal death and composite neonatal morbidity for liveborn infants ≥28 weeks. Adjusted risk ratios (ARR) and 95% confidence intervals (CI) were determined. RESULTS: Five thousand, six hundred and ninety-eight births/miscarriages were potential index deliveries. Of these, 2175 women had an eligible subsequent pregnancy: 108 received cerclage at <14 weeks gestation, 2067 did not. Women with cerclage were significantly more likely to deliver <37 weeks than those without (39.8% vs 19.3%, ARR 1.92, 95% CI 1.48-2.48), and had increased risks of PPROM (ARR 4.38, 95% CI 2.62-7.32) and stillbirth/neonatal death (ARR 2.20, 95% CI 1.02-4.73). Following cerclage, liveborn infants ≥28 weeks had double the risk of severe morbidity (ARR 2.54, 95% CI 1.55-4.16). CONCLUSIONS: In women with a single previous midtrimester delivery, cervical cerclage <14 weeks gestation in subsequent pregnancy was associated with worse pregnancy outcomes.

Mortality, rehospitalizations and costs in children undergoing a cardiac procedure in their first year of life in New South Wales, Australia.

BACKGROUND: Cardiac procedures are part of management for many children with congenital heart disease (CHD). Using population health data, this study explores health outcomes of children undergoing a cardiac procedure in the first year of life to better understand the impact of CHD on children, families and health services. METHODS AND RESULTS: A population-based record-linkage cohort study was undertaken. Rate of cardiac procedures in the first year of life over the study period 2001-2012 in New South Wales, Australia, was steady at 2.5 children per 1000 live births, accounting for 2722 children. Excluding those with isolated closure of patent ductus arteriosus (n=416), 50% required readmission in the first year of life. Over 1/5th had an additional non-cardiac congenital anomaly. Average total cost per infant for initial procedure admission was $67,054 AUD ($63,124-$70,984) with a median length of stay (LOS) 13days (IQR 8-23). Average cost per readmission in the first year of life was $11,342 (95% CI 10,361-$12,323) with median LOS 2days (IQR 1-5). Mortality rate in the 30days following initial procedure was 3.1% (72/2306). Mortality rate by age 1year was 7.1%, and 13.8% for those who had neonatal surgery. CONCLUSION: Risk of mortality in operatively-managed CHD extends beyond the immediate perioperative period. Children undergoing a cardiac procedure in their first year are often readmitted to hospital for both further planned procedures and unplanned reasons such as infection. These readmissions capture the significant impact of illness and pose substantial financial cost to the health system.

Induction of labour practices in New South Wales hospitals: Before and after a statewide policy.

Midwifery Unit Managers completed surveys in 2008 and 2014 to determine methods of induction of labour. There was an increase in balloon catheter use for cervical ripening (rate difference 37%, P = 0.007). Currently, all respondent hospitals have an oxytocin protocol; district hospitals had a significant increase in use of post-maturity protocols (rate difference = 40%, P = 0.01) but there was no change in use of prostaglandin protocols.

Exploring pneumonia risk factors in Vietnamese infants: a survey of new mothers.

OBJECTIVE: To understand the prevalence of pneumonia risk factors and perceived barriers to risk factor reduction among Vietnamese infants. METHODS: We conducted a cross-sectional survey of mothers in the postnatal wards of Da Nang Hospital for Women and Children in central Vietnam from 10 February 2017 to 24 February 2017. RESULTS: Of 286 mothers surveyed, 259 (91%) initiated breast feeding and 207 (72%) intended to continue exclusive breast feeding for 6 months. No mother smoked cigarettes, but 42% of fathers did. Mothers' decision not to smoke was motivated by concerns for their own health and that of their baby. Households rarely used wood or coal for cooking (6%). Mothers indicated near universal (99%) uptake of the National Expanded Program of Immunization vaccinations. Few (64; 22%) mothers knew about the pneumococcal conjugate vaccine; 56/64 (88%) indicated that they would purchase it for their infants. Family members rarely influenced mothers' decisions about breast feeding or vaccination, except in two instances where fathers were concerned about vaccine-related adverse effects. CONCLUSION: Modifiable pneumonia risk factors were uncommon among newborn babies in central Vietnam, apart from paternal cigarette smoke exposure. Successful local implementation of the WHO Essential Newborn Care package as well as high levels of maternal education and decision autonomy was observed.

Long-term childhood outcomes of breech presentation by intended mode of delivery: a population record linkage study.

INTRODUCTION: There is a lack of information on long-term outcomes by mode of delivery for term breech presentation. We aimed to compare childhood mortality, cerebral palsy, hospitalizations, developmental, and educational outcomes associated with intended vaginal breech birth (VBB) with planned cesarean section. MATERIAL AND METHODS: Population birth and hospital records from New South Wales, Australia, were used to identify women with non-anomalous pregnancies eligible for VBB during 2001-2012. Intended mode of delivery was inferred from labor onset and management. Death, hospital, and education records were used for follow up until 2014. Cox proportional hazards regression and modified Poisson regression were used for analysis. RESULTS: Of 15 281 women considered eligible for VBB, 7.7% intended VBB, 74.2% planned cesarean section, and intention was uncertain for 18.1%. Intended VBB did not differ from planned cesarean section on infant mortality (Fisher's exact p = 0.55), childhood mortality (Fisher's exact p = 0.50), cerebral palsy (Fisher's exact p = 1.00), hospitalization in the first year of life [adjusted hazard ratio (HR) 1.04; 95% CI 0.90-1.20], hospitalization between the first and sixth birthdays (HR 0.92; 95% CI 0.82-1.04), being developmentally vulnerable [adjusted relative risk (RR) 1.22; 95% CI 0.48-1.69] or having special needs status (RR 0.95; 95% CI 0.48-1.88) when aged 4-6, or scoring more than 1 standard deviation below the mean on tests of reading (RR 1.10; 95% CI 0.87-1.40) and numeracy (RR 1.04; 95% CI 0.81-1.34) when aged 7-9. CONCLUSIONS: Planned VBB confers no additional risks for child health, development or educational achievement compared with planned cesarean section.

Women's views about the timing of birth.

BACKGROUND: Estimated date of birth (EDB) is used to guide the care provided to women during pregnancy and birth, although its imprecision is recognised. Alternatives to the EDB have been suggested for use with women however their attitudes to timing of birth information have not been examined. AIMS: To explore women's expectations of giving birth on or near their EDB, and their attitudes to alternative estimates for timing of birth. METHODS: A survey of pregnant women attending four public hospitals in Sydney, Australia, between July and December 2012. RESULTS: Among 769 surveyed women, 42% expected to birth before their due date, 16% after the due date, 15% within a day or so of the due date, and 27% had no expectations. Nulliparous women were more likely to expect to give birth before their due date. Women in the earlier stages of pregnancy were more likely to have no expectations or to expect to birth before the EDB while women in later pregnancy were more likely to expect birth after their due date. For timing of birth information, only 30% of women preferred an EDB; the remainder favoured other options. CONCLUSIONS: Most women understood the EDB is imprecise. The majority of women expressed a preference for timing of birth information in a format other than an EDB. In support of woman-centred care, clinicians should consider discussing other options for estimated timing of birth information with the women in their care.

"Very Good" Ratings in a Survey of Maternity Care: Kindness and Understanding Matter to Australian Women.

BACKGROUND: Surveys have shown that women are highly satisfied with their maternity care. Their satisfaction has been associated with various demographic, personal, and care factors. Isolating the factors that most matter to women about their care can guide quality improvement efforts. This study aimed to identify the most significant factors associated with high ratings of care by women in the three maternity periods (antenatal, birth, and postnatal). METHODS: A survey was sent to 2,048 women who gave birth at seven public hospitals in New South Wales, Australia, exploring their expectations of, and experiences with maternity care. Women's overall ratings of care for the antenatal, birth, and postnatal periods were analyzed, and a number of maternal characteristics and care factors examined as potential predictors of "Very good" ratings of care. RESULTS: Among 886 women with a completed survey, 65 percent assigned a "Very good" rating for antenatal care, 74 percent for birth care, 58 percent for postnatal care, and 44 percent for all three periods. One factor was strongly associated with care ratings in all three maternity periods: women who were "always or almost always" treated with kindness and understanding were 1.8-2.8 times more likely to rate their antenatal, birth, and postnatal care as "Very good." A limited number of other factors were significantly associated with high care ratings for one or two of the maternity periods. CONCLUSIONS: Women's perceptions about the quality of their interpersonal interactions with health caregivers have a significant bearing on women's views about their maternity care journey.