The health promotion program focuses on developing new ways to enhance the health of women and their families and minimise their exposure to risks that threaten their health and well-being.
Through the projects in this program we have been able to critically analyse and generate the best available evidence and identify strategies to translate our findings into practice.
Our projects include the design of education programs for health professionals to help build capability in health literacy and promotion. This program focuses on innovations in integrated service design for women and families in order to address holistic needs.
A number of projects have been completed or are currently underway, including:
Perinatal Mental Health
We have conducted projects in this area since 2000.
Each project leads to the use of best available evidence to develop, implement and evaluate primary prevention and health promotion interventions or programs that improve the well-being of women and their families.
Our specific focus is on primary prevention of perinatal mental health problems (such as anxiety, postnatal depression (PND), fear of birth, and trauma symptoms).
Study 1 – Effectiveness of caseload midwifery care in promoting maternal mental health and positive mother-infant relationships (MoMent Study) (2017-2020)
Around 19% of women experience a perinatal mental health disorder, which has long-term consequences for themselves, their families, and society.
There is an urgent need for nation-wide, population level, research-informed information that will allow maternity service planners to implement models that address healthcare needs, are accepted by women and are cost-effective.
This mixed methods project aims to:
- identify the effectiveness of public hospital continuity of midwifery care (COMC), public hospital standard care on perinatal mental health outcomes
- explore women’s experiences of different models of care, and the impact of their birthing experience on their likely future decision-making
- quantify the cost-effectiveness of different models of care from a public hospital perspective to identify the costs involved in delivering different models.
Pregnant women (n = 309) were recruited and completed online surveys at five different times: at their first hospital pregnancy appointment, at 36 weeks, the week of birth and at 6 weeks and 6 months following birth. Surveys asked about women’s physical, mental and social well-being. Following birth, we collected information regarding mother-infant relationships, breastfeeding and birth experience as well as electronic hospital data.
There were beneficial outcomes for women who received caseload care compared to non-caseload care. For example, women in caseload were less likely to birth a preterm baby, less likely to have their labours induced, less likely to have an epidural and less likely to birth their baby by caesarean section. They were also more likely to experience water immersion during labour and waterbirth. There were no differences in terms of mental health, physical health or social support. Our study made an important contribution to validating the tools included in the ICHOM core outcome set. Our study facilitates a standardised way to collect a comprehensive set of outcome data in clinical practice which will enable the transformation of health care systems within and across states, as well as countries. The results from our study addresses two national health priority areas – mental health and healthy start to life; and supports the next phase of the implementation of the National Maternity Services Plan
Publications and presentations:
Slavin V, Gamble J, Creedy DK, Fenwick J, & Pallant J. (2019). Measuring physical and mental health during pregnancy and postpartum in an Australian childbearing population. Validation of the PROMIS Global Short Form. BMC Pregnancy and Childbirth, 19,370. https://doi.org/10.1186/s12884-019-2546-6
Slavin, V., Gamble, J., Creedy, D. K., & Fenwick, J. (2018). “Coming of age”: Assessing the feasibility of using a core set of value-based health outcomes for pregnancy and childbirth. Women and Birth, 31, S29-S30. https://doi.org/10.1016/j.wombi.2018.08.092 Paper presented at the Australian College of Midwives National Conference, Perth, 16–18 October 2018.
Gamble, J., Slavin, V., Creedy, D. K., & Fenwick, J. (2018). Effectiveness of caseload midwifery care in promoting maternal physical, mental and social health during pregnancy and birth. 21st Congress of the Nordic Federation of Midwives, Reykjavik, May 2019
Study 2 – Translation to practice: Implementing a midwife psycho-education intervention to improve women’s perinatal mental health (2016-2018)
Getting clinicians to base their practice on best available evidence is challenging.
This study tested the implementation of a midwifery-led psycho-education intervention to promote women’s mental health into practice.
The study determined the extent to which characteristics of midwives, the model of service delivery, policies and procedures, and delineation of roles of multidisciplinary team members impacted on midwives implementing the intervention and outcomes of care delivered to childbearing women.
Across the life of the project, information was progressively collected and evaluated to inform strategies to remediate barriers to practice translation.
Gamble, J., Toohill, J., Slavin, V., Creedy, D. K., & Fenwick, J. (2017). Identifying barriers and enablers as a first step in the implementation of a midwife-led psychoeducation counseling framework for women fearful of birth. International Journal of Childbirth, 7(3), 152-168. DOI:10.1891/2156-52126.96.36.199
Fenwick J, Toohill J, Slavin V, Creedy DK. & Gamble J. (2018) Improving psychoeducation for women fearful of childbirth: Evaluation of a research translation project. Women & Birth, 31(1):1-9. doi: 10.1016/j.wombi.2017.06.004
Toohill J, Fenwick J, Sidebotham M, Gamble J, & Creedy, DK. (2019) Trauma and fear in Australian midwives. Women & Birth 32(1): 64-71. doi.org/10.1016/j.wombi.2018.04.003
Study 3 – Reducing childbirth related fear and preference for caesarean section: A RCT of a midwifery led psycho-education intervention (BELIEF Study) (2012 – 2016)
For first-time mothers, fear is often linked to a perceived lack of control and disbelief in the body’s ability to give birth safely, whereas multiparous women may be fearful due to previous negative and/or traumatic birth experiences.
A brief psycho-education intervention was offered during pregnancy by trained midwives. The BELIEF intervention (Birth Emotions – Looking to Improve Expectant Fear) reduced women’s childbirth fear; decisional conflict; and depressive symptoms; while improving childbirth self-efficacy; and health and obstetric outcomes.
In study 2 (above) we investigated how best to implement our positive findings into practice, and in the MoMent study (above) we extended the work to determine how effective relationship-based care is in supporting and promoting women’s mental health around the time of birth.
Toohill J, Callander E, Fox H, Lindsay D, Gamble, J. Creedy DK. & Fenwick J. (2019) Socioeconomic differences in access to care for women fearful of birth in Australia. Australian Health Review, 43(6): 639-643. doi.org/10.1071/AH17271
Fenwick J, Toohill J, Slavin V, Creedy DK. & Gamble J. (2018) Improving psychoeducation for women fearful of childbirth: Evaluation of a research translation project. Women & Birth, 31(1):1-9. doi:10.1016/j.wombi.2017.06.004
Toohill J; Callander E, Gamble J, Creedy DK, & Fenwick J. (2017) A cost effectiveness analysis of midwife psycho-education for fearful pregnant women – a health system perspective for the antenatal period. BMC Pregnancy and Childbirth 17, 217. DOI 10.1186/s12884-017-1404-7
Fenwick J, Toohill J, Gamble J, Creedy DK, Buist A, Turkstra E, Sneddon A, Scuffham PA, & Ryding EL. (2015) Effects of a midwife psycho-education intervention to reduce childbirth fear on women’s birth outcomes and psychological well-being. BMC Pregnancy & Childbirth, 15, 284 DOI 10.1186/s12884-015-0721-y
Toohill J, Creedy DK, Gamble J, & Fenwick J. (2015) A cross-sectional study to determine utility of childbirth fear screening in maternity practice: an Australian perspective. Women & Birth, 28, 310-316. https://doi.org/10.1016/j.wombi.2015.05.002
Fenwick J, Toohill J, Creedy DK, Smith J & Gamble J. (2015). Sources, responses and moderators of childbirth fear in Australian women: a qualitative investigation. Midwifery, 31(1), 239-246. https://doi.org/10.1016/j.midw.2014.09.003
Fenwick J, Gamble J Creedy DK, Buist A, Turska E. Sneddon A, Scuffham P, Ryding E, Jarrett V. & Toohill J. (2013). Study protocol for reducing childbirth fear: A midwife-led psycho-education intervention. BMC Pregnancy & Childbirth 13,190. https://doi.org/10.1186/1471-2393-13-190
Study 4 – Improving postpartum women’s mental health: A RCT of a midwife-led counselling intervention (PRIME)
We investigated the impact of pre-existing ill mental health on postpartum maternal outcomes. Women reporting childbirth trauma received counselling (Promoting Resilience in Mothers’ Emotions [PRIME]; n =137) or parenting support (n =125) at birth and 6 weeks.
At 12 months, it was found that PRIME had improved women’s quality of life, parenting confidence and emotional wellbeing.
Turkstra E, Creedy DK, Fenwick J, Buist A, Scuffham PA. & Gamble J. (2015). Health services utilization of women following a traumatic birth. Archives of Women’s Mental Health, 18(6), 829-832. https://doi.org/10.1007/s00737-014-0495-7
Reed M, Fenwick J, Hauck Y, Gamble J. Creedy DK. (2014). Australian midwives’ experience of delivering a counselling intervention for women reporting a traumatic birth. Midwifery, 30 (2), 269-275. https://doi.org/10.1016/j.midw.2013.07.009
Boorman R, Devilly G J, Gamble, J, Creedy DK, Fenwick J. (2014). Childbirth and criteria for traumatic events. Midwifery, 30(2), 255-261 http://dx.doi.org/10.1016/j. midw.2013.03.001
Turkstra E, Gamble J, Creedy DK, Fenwick J, Barclay L, Buist A, Ryding E. & Scuffham PA. (2014). PRIME: Impact of previous mental health problems on health-related quality of life in women with childbirth trauma. Archives of Women’s Mental Health, 16(6), 561-564. DOI 10.1007/s00737-013-0384-5
Fenwick J, Gamble J, Creedy D, Barclay L Buist A, & Ryding EL. (2012). Women’s perceptions of emotional support following childbirth: A qualitative investigation. Midwifery, 29(3), 217-224. https://doi.org/10.1016/j.midw.2011.12.008
Study 5 – A couple-based program for the transition to parenthood (Couple Care) (2005-2007)
Most couples have significant struggles adapting to the challenges of parenthood.
For about 60% of couples their relationship deteriorates significantly, the health of many individuals deteriorates, and their children’s development does not flourish as well as it could.
In this study, couples expecting their first child were randomly assigned to either Becoming a Parent (BAP), a maternal parenting education program; or Couple CARE for Parents (CCP), a couple relationship and parenting education program.
Couples were assessed pre-intervention (last trimester of pregnancy), post-intervention (5 months postpartum), and follow-up (12 months postpartum).
Relative to BAP, CCP reduced negative couple communication, and prevented erosion of relationship adjustment and self-regulation in women but not men.
Parenting stress reduced in both groups. Couple Care for Parents shows promise as a brief program that can enhance couple communication and women’s adjustment to parenthood.
Halford KW, Petch J, & Creedy DK (2015). Clinical guide to helping new parents: The Couple CARE Program. Springer New York. (170 pages) doi:10.1007/978-1-4939-1613-9
Petch J, Halford W.K., Creedy DK, & Gamble J. (2012). A randomised controlled trial of a couple relationship and co-parenting program (Couple CARE for Parents) for high- and low-risk new parents. Journal of Consulting and Clinical Psychology, 80(4), 662-73. DOI: 10.1037/a0028781
Petch J, Halford W.K., Creedy DK, & Gamble J. (2012). Couple relationship education at the transition to parenthood: A window of opportunity to reach high risk couples. Family Process, 51,(4), 489-511. https://doi.org/10.1111/j.1545-5300.2012.01420.x
Halford W, Petch J, Creedy DK & Gamble J. (2011). Intimate partner violence in couples seeking relationship education for the transition to parenthood. Journal of Couple & Relationship Therapy, 10(2), 152-168. https://doi.org/10.1080/15332691.2011.562835
Halford, WK, Petch, J, Creedy, DK. (2010). Promoting a positive transition to parenthood: a randomized clinical trial of couple relationship education. Prevention Science, 11(1), 89-100. https://doi.org/10.1007/s11121-009-0152-y
Study 6 – Childbirth and the development of acute trauma symptoms (2000)
Little is known about the relationship between women’s birthing experiences and the development of trauma symptoms.
Using a prospective, longitudinal survey design, 499 women in their last trimester of pregnancy were recruited from four public hospital antenatal clinics.
Telephone interviews at 4 to 6 weeks and 3 months postpartum explored the medical and midwifery management of the birth, perceptions of intrapartum care, and the presence of trauma symptoms.
One in three women (33%) identified a traumatic birthing event. Twenty-eight women (5.6%) met diagnostic criteria for acute posttraumatic stress disorder.
The level of obstetric intervention experienced during childbirth and the perception of inadequate intrapartum care during labour was also associated with trauma symptoms.
Women who experienced both a high level of obstetric intervention and dissatisfaction with their intrapartum care were more likely to develop trauma symptoms than other women.
These findings should prompt a serious review of intrusive obstetric intervention during labour and birth, and the care provided to birthing women.
Creedy, D. Shochet, I. & Horsfall, J. (2000). Childbirth and the development of acute trauma symptoms. Birth, 27(2), 104-111. https://doi.org/10.1046/j.1523-536x.2000.00104.x Article reprinted in full MIDIRS Midwifery Digest, (2000). 10(4), 491-497.
Creedy, D. (2000). Postnatal depression and posttraumatic stress disorder: What are the links? Birth Issues, 8(4), 125-130.
Health literacy is people’s knowledge, motivation and competence to access, understand, appraise and apply health information in order to make informed judgments and decisions about their health. This might include decisions about health care options, illness prevention or ways to improve their quality of life.
This project aims to improve and develop health literacy capability among women and their families in order to empower them to make better and more informed decisions about their care and health.
Creedy DK, Gamble, J, Boorman R. & Allen J. (2020) Midwives’ knowledge and reported practices to assess and address maternal health literacy: A cross-sectional survey. Women & Birth, in press. https://doi.org/10.1016/j.wombi.2020.02.018
Study 1 – Measuring health literacy
There are many instruments measuring either health literacy in general or a dimension of health literacy (e.g. numeracy), health literacy related to specific issues (e.g. nutrition, diabetes) or health literacy in relation to specific populations (e.g. adolescents).
However, there is relatively little research on the health literacy of childbearing women. Furthermore, there are currently no instruments that specifically assess midwives’ understanding of health literacy and how they may assess women’s health literacy in practice.
Measurement and understanding of health literacy at the woman and clinician level may support midwives to better understand the needs of childbearing women and enable a deeper engagement with healthcare services.
We are developing a tool to measure midwives’ understanding of health literacy and are seeking expert opinion and conducting a national survey as part of this process.
Study 2 – Provision of training
Education and training is critical to raising midwives’ level of health literacy and to better detect women’s knowledge or skills relevant to the perinatal period.
Training on health literacy may assist midwives to provide improved care. The results of our forthcoming national survey will identify gaps in our understanding and help inform training content to achieve better learning processes and outcomes.
Domestic and Family Violence
Domestic and family violence affects over a third of women globally. For many women, domestic and family violence (DFV) may commence or escalate during pregnancy. Therefore, the maternity service response to DFV is critical to the well-being of women and their unborn/newborn babies. While progress has been made towards addressing identified gaps, several significant challenges still remain.
Study 1 – Women’s Experiences of domestic and family violence screening during pregnancy
There has been growing research on women’s attitudes and beliefs about DFV screening, but relatively few studies on women’s experiences of screening during pregnancy. The aim of this study is to determine pregnant women’s experiences of DFV screening by midwives. Pregnant women (n = 210) attending an antenatal service were surveyed about their experiences of screening and asked to complete three new measures: Beliefs about DFV Screening; Non-disclosure of DFV; and Midwifery Support.
Creedy, D., Baird, K., Gillespie, K. (2019). A cross-sectional survey of pregnant women’s perceptions of routine domestic and family violence screening and responses by midwives: Testing of three new tools. Women and Birth, In press.
Study 2 – Women’s experiences of maternity care in responding to domestic and family violence using a Trauma and Violence Informed Care Framework
Women are at greater risk of experiencing violence from an intimate partner during pregnancy and the post-partum period, with 1 – 6 experiencing violence. Using a trauma informed and violence framework this qualitative study examined women’s experiences of a large tertiary maternity care services in detecting and responding to domestic and family violence.
The voices of women who have experienced DFV were foregrounded in this study to highlight facilitators, barriers and recommendations for improving detection and response to DFV in the context of maternity services. The feasibility of a newly developed Trauma and Violence Informed Care framework (TVIC) was used and tested in this study as a systematic approach to detection and response to DFV.
10 women participated in the study, all the women had experienced DFV during their pregnancy and in the postpartum period. Based on preliminary analyses of interviews with the women, themes to emerge revealed: (1) “Clued-in” HCP’s for skilled questioning, (2) Benefits of DFV-trained specialists, (3) Organisational barriers to ‘safe space’ creation, (4) Linkages with external agencies and informal support, and finally, (5) Universal and targeted information for DFV awareness-raising. The study identified the enablers, challenges and recommendations for improving detection and response to DFV in the context of maternity services from the perspective of women who have experienced DFV. The feasibility of a newly developed Trauma and Violence Informed Care framework (TVIC) has been used in this study by evaluating the current DFV response of maternity services. The findings of the research project contribute to improving the capacity of health professionals and the wider healthcare services to best meet the needs of vulnerable women and families with DFV.
Study 3 – Domestic and Family Violence in Maternity Care: Applying a Trauma and Violence Informed Care Framework
This research builds on our recent work by taking a ‘step back’ to systematically reassess and identify how and why DFV response work gets done in our maternity services, how women and clinicians experience DFV assessment and responses, and the related costs incurred.
The mixed methods project will use a recently developed Trauma and Violence Informed Care (TVIC) framework that has four interrelated and connected pillars, including relationship building, integrated coordinated care, reflective systems and continual assessment of work environment.
Working within these pillars will help guide data collection and analysis. The evidence gained from this project will provide an enhanced strategic oversight of how we can better optimise and sustain an integrated staff response to DVF, ensuring service delivery is woman-centred and aligns to best practice.
Study 4 – Exploring staff detection and response to Domestic and Family Violence in Clinical Practice
Routine enquiry about Domestic & Family Violence (DFV) during pregnancy has been implemented by many health services in Australia but often without comprehensive staff training, system changes and referral processes.
This study (Breaking the Silence) explores the experiences of midwives and other health care clinicians working within the maternity services around DFV assessment and responses. All staff working within maternity services will be invited to complete an online anonymous survey. The survey will seek to determine the barriers to responsibilities and referral pathways and define the barriers to identifying and supporting women who are experiencing DFV.
Analysis of this data is in progress.
Study 5 – What are the service costs associated with DFV in the childbearing population?
Domestic and family violence (DFV) can have a severe and enduring effect on a woman’s physical and mental health. Using a burden of disease methodology, domestic violence was found to be the leading risk factor contributing to death, disability and illness in women aged 25 to 44 years.
Due to the hidden nature of DFV, there is a lack of financial data for disease burden. Using a cost analysis of hospital activity, this study will focus on understanding the costs associated with DFV in pregnancy. An economic model will be developed which will calculate the cost burden associated with DFV including injury, and ongoing medical costs.
Promoting physiological and humanised birth
This overall aim of this programme of research is to progress knowledge about the humanisation of childbirth. It consists of four main research strands: birth environment, birth physiology, birth ethics and birth technology.
This builds on the work from Dr. Newnham’s PhD – a critical ethnography of a hospital labour ward, with a focus on epidural analgesia.
Two theoretical concepts derived from this work are the Paradox of the institution (figure 1) and the Circle of trust (figure 2).
Figure 1 Paradox of the institution
Figure 2 Circle of Trust
Publications: Newnham E, McKellar L & Pincombe J 2018. Towards the humanisation of birth: A study of epidural analgesia and hospital birth culture. Palgrave Macmillan, Basingstoke.
Newnham, E, McKellar, L & Pincombe, J 2017. ‘It’s your body, but…’ Mixed messages in childbirth education: findings from a hospital ethnography, Midwifery 55: 53–59. https://doi.org/10.1016/j.midw.2017.09.003
Newnham, E, McKellar, L & Pincombe, J 2017. Paradox of the institution: findings from a hospital labour ward ethnography, BMC Pregnancy and Childbirth 17(1): 2-11. https://doi.org/10.1186/s12884-016-1193-4
Newnham E, McKellar L & Pincombe, J 2016. A critical literature review of epidural analgesia, Evidence Based Midwifery 14(1): 22-28.
Newnham E, McKellar L & Pincombe, J 2015. Documenting risk: A comparison of policy and information pamphlets for using epidural or water in labour, Women & Birth 28(3): 221-227. https://doi.org/10.1016/j.wombi.2015.01.012
Humanising Birth series for The Practising Midwife
Newnham E & Page L 2019. Humanisation of childbirth series article 1: The humanisation of childbirth. The Practising Midwife, 22(8): 14-17.
Newnham E 2019. Humanisation of childbirth series article 2: The circle of trust. The Practising Midwife, 22(9): 15-19.
Newnham E, Karlsdottir SI & Sanders, R 2019. Humanisation of childbirth series article 3: Re-envisaging labour pain – a humanistic approach. The Practising Midwife, 22(10): 14-17.
Newnham, E 2019. Humanisation of childbirth series article 4: The paradox of the institution. The Practising Midwife, 22(11): 16-19.
Newnham, E 2020. Humanisation of childbirth series article 5: Humanising policy – the curious case of epidural analgesia and water immersion. The Practising Midwife, 23(1): 14-17.
Newnham, E 2020. Humanisation of childbirth series article 6: Midwifery technology – Midwifery practice for the humanisation of birth. The Practising Midwife, 23(2): 14-17.
Bass, J., McKellar, L., & Newnham, E. Humanisation of childbirth series article 7: The role of critical pedagogy in midwifery education. The Practicing Midwife, 23(3).
Page, L., & Newnham, L. Humanisation of childbirth series article 8: Where do we go from here? The Practicing Midwife, 23(4).
Study 1 – Exploring women’s views of labour pain: a collaborative research approach
Our aim is to further investigate women’s views about pain in labour, using a co-design research method, and based in the concepts of salutogenesis (focusing on factors that help create wellbeing) (Downe & McCourt 2008) and humanisation of birth (with its tenets of respect, relationship, embodiment) (Davis-Floyd, 2018) that focuses on these positive aspects of pain.
Publications to date: Newnham, E & Karlsdottir, IS. 2019. Exploring women’s views of labour pain: a collaborative research approach. Congress of the Nordic Federation of Midwives, Midwifery Across Borders. Harpa, Reykyavik, 2-4th May, Poster presentation.
Other related publications/activities: Newnham E, Moran P, Carroll M, Begley C, Daly D. 2020. Comparison of outcomes between nulliparous women who used epidural analgesia in labour and those who did not: a prospective cohort study. Trinity Health and Education International Research Conference 2020, Dublin, Ireland 3-5th March, Oral presentation.
Newnham E. 2019. Bare Autonomy: Power and ethics in contemporary maternity care. Australian College of Midwives 22nd annual conference – Power, passion and politics, Canberra, Australia 17-19th September, Oral presentation.
Karlsdottir SI, Newnham E, Kristjansdottir H & Sanders R 2019. Decision-making around pain and its management during labour and birth. In E Jefford & J Jomeen (eds.) Empowering Decision-Making in Midwifery: A Global Perspective. Routledge, Abingdon.
Leap N, Newnham E, Karlsdottir I. 2019. Approaches to pain in labour: implications for midwifery practice. In S Downe & S Byrom (eds.) Squaring the Circle: researching normal childbirth in a technological world. Pinter and Martin, London.
Karlsdóttir, SI, Newnham, E & Leap N. 2019. How can midwives support women to work with pain in labour? Congress of the Nordic Federation of Midwives, Midwifery Across Borders, Harpa, Reykyavik, 2-4th May, Conference Workshop.
Newnham E & Kirkham M. 2019. Beyond autonomy: Care ethics for midwifery and the humanization of birth, Nursing Ethics 26(7-8):2147-2157. https://doi.org/10.1177/0969733018819119
Newnham, E. 2018. Women’s experiences of pain in labour: developing the case for a salutogenic approach to childbirth pain. COST Action BIRTH Conference – From Birth to Health: Towards Sustainable Childbirth, Lisbon, Portugal, 17-18th September, Oral presentation.
Newnham, E. 2018. The circle of trust: pain, embodiment and the midwife-women relationship in labour. Icelandic Association of Midwives National conference, Akureyri, Iceland, 5th May, Invited Keynote.
Newnham E. 2017. Ethics of care: a way towards humanised birth. Conference paper, Normal Labour and Birth Research Conference, University of Central Lancashire, Grange-over-Sands, UK, 2-4th October, Oral presentation.
Newnham E 2014. Birth control: Power/knowledge in the politics of birth, Health Sociology Review 23(3): 254-268. https://doi.org/10.1080/14461242.2014.11081978