Generating and translating existing and new research into maternity care is critical to the provision and delivery of safe, transparent, effective and efficient services.
Transforming Maternity Care Collaborative is working with consumers and health services to implement strategies to reform the delivery of maternity services to align with best practice evidence and to generate evidence where it does not exist.
Advancing quality maternal and newborn care
Study 1 – Testing an internationally agreed Set of Standard Outcome Measures for Pregnancy and Childbirth (ICHOM)
Measurement of maternity care plays a vital role in ensuring quality care and continuous improvement, but current healthcare quality metrics may be missing the mark.
Current outcome measures focus on processes and systems and pay limited attention to outcomes impacting the long-term health of mothers and babies or women’s views about their health and care.
The ICHOM Standard Set of Outcome Measures for Pregnancy and Childbirth consists of well-known measurement scales, relatively new scales, and discrete items which are important to women and may be useful in transforming healthcare within and across health services and systems through benchmarking.
This project, which forms part of Ms Slavin’s PhD, is an Australian first and aims to test the feasibility of the Standard Set of Outcome Measures in terms of validity and reliability of the included measures, for the birthing population.
Around 300 women have been recruited for this study and completed the Standard Set of Outcome Measures during pregnancy, around the time of birth and up to 6 months postpartum.
Slavin, V., Gamble, J., Creedy, DK., Fenwick, 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(1), 370. DOI: 10.1186/s12884-019-2546-6
Slavin, V., Gamble, J., Creedy, DK., Fenwick, J. (2019). Perinatal Incontinence: Psychometric evaluation of the International Consultation on Incontinence Questionnaire – Urinary Incontinence Short form and Wexner scale. Neurourology and Urodynamics, 38(8) 2209-2223. DOI: 10.1002/nau.24121
Slavin, V., Creedy, DK., Gamble, J. (2020). Benchmarking outcomes in Maternity Care: Peripartum incontinence – a framework for standardised reporting. Midwifery, 83, 102628. DOI: 10.1016/j.midw.2020.102628
Study 2 – Evaluation of maternity services using the Framework for Quality
Maternal and Newborn Care
In 2014, The Lancet series on Midwifery published an evidence-based framework for Quality Maternal and Newborn Care (QMNC).
This sub-program of work uses the QMNC to evaluate maternity services and make recommendations for service enhancement to align with all elements of the Framework.
Study 3 – Logan Community Maternal and Child Health Hubs
Logan City, south of Brisbane, continues to experience disproportionate levels of disadvantage. Pregnant women in this area are less likely to access antenatal care even when established health services are available. New approaches were needed to address these issues and Transforming Maternity Care Collaborative participated in a wider process to co-design for for purpose services
The Logan Community Maternal and Child Health Hubs aimed to address the specific needs of women and families experiencing the greatest disadvantage. The new model includes providing continuity of midwifery care with a named midwife for all women. The Hubs are located in existing, non-government community organisations, which offer a range of social and health services. Integrated support from established secondary and tertiary maternity services are provided through Logan Hospital.
The service specifically aims to meet the needs of women from migrant and refugee communities, Aboriginal and Torres Strait Islander women, and women experiencing low SES circumstances. It is underpinned by principles of primary health, community development, co-design and cultural safety.
Our team continues to work in partnership with Metro South Health Service, Health Consumers Queensland, and Logan Together to assess impact, sustainability and scalability of this innovative community-based maternity and child health service.
This study is also relevant to the Health Promotion Program.
Health economics and maternal and infant health
Study 1 – Maternity 1000
The project seeks to quantify the value associated with different models of maternity care by assessing the difference in outcomes versus the cost implications. The project considers both costs and outcomes over the First 1,000 days’ time period, allowing longer term impacts to be captured.
Costs will be assessed from both the health system’s perspective, and the individual’s perspective. This project uses a linked administrative dataset of 186,000 women who gave birth in Queensland in the 2012 – 2015 time period.
This dataset is called Maternity1000 and contains information from the Perinatal Data Collection, Admitted Patient Data Collection, Emergency Department Information System, Medicare Benefits Schedule claims records, and Pharmaceutical Benefits Scheme claims records. As such, it contains a detailed record, at the individual level, of each woman’s and child’s health service use during pregnancy and up to two years following birth.
This project comes at a time when health policy makers are seeking solutions for more efficient means of providing maternity care. The outcomes of this project will provide previously unavailable information on the value of different models of care to the health system and to its users.
Study 2 – Patient decision-making and the increasing costs of maternal healthcare
This project could be the answer to the question many women’s ask when they are weighing up maternity care options – how much will maternity care cost me?
This project aims to quantify the out-of-pocket fees paid by women in different locations for various forms of maternity care. Outcomes from this study will be available to women in the near future to enable them to make more informed decisions about their care options during pregnancy.
The proportion of women birthing in private hospitals has declined significantly in recent years. Out-of-pocket costs of private care are potentially influencing women’s decision-making.
An initial study undertaken by Associate Professor Callander indicated that since 1993 the largest increase in the cost of any MBS service was for out-of-hospital obstetrics, with an increase of 1,035%. Out-of-pocket costs for in-hospital services rose by 77%. These figures were adjusted for inflation and revealed a staggering increase in the amount being charged to women.
Pregnant women can access care within a public hospital free of charge at the time of birth, if they choose. However, during the pregnancy they still may face out-of-pocket charges for primary care and diagnostic services. Furthermore, those accessing private care may be unaware of the out-of-pocket fees for private services.
Callander, E., Topp, S., Fox, H., Corscadden, L. (2020). Out-of-pocket expenditure on health care by Australian mothers: Lessons for maternal health coverage from a long-established system. Birth, 47(1), 49 – 56. https://doi.org/10.1111/birt.12457
Study 3 – Economic evaluation of maternal health interventions
Associate Professor Callander is evaluating a number of interventions and services that are proposed, or have been implemented, into routine maternity care across Australia.
The aim of these studies is to quantify the costs associated with using these interventions relative to the outcomes they achieve.
This study is being conducted in collaboration with a number of leading research groups, including the Mater Research Institute, the NHMRC Clinical Trials Centre, and service providers, such as the Gold Coast University Hospital. These interventions include:
- novel treatments of iron deficiency anaemia in pregnancy,
- monitoring fetal movements,
- continuity of midwifery care, and
- utilising participatory women’s groups to improve quality of Indigenous women’s pregnancy care.
Callander, E., Creedy, DK., Gamble, J., Fox, H., Toohill, J., Sneddon, A., Ellwood, D. (2019). Reducing caesarean delivery: An economic evaluation of routine induction of labour at 39 weeks in low-risk nulliparous women. Paediatric and Perinatal Epidemiology, 34(1), 3 – 11. https://doi.org/10.1111/ppe.12621
Flenady, V., Gardener, G., Boyle, FM., Callander, E., et al. (2019). My Baby’s Movements: A stepped wedge cluster randomised controlled trial to raise awareness of fetal movements during pregnancy study protocol. BMC Pregnancy Childbirth, 19, 430. https://doi.org/10.1186/s12884-019-2575-1
Enablers and barriers to the reform of maternity services
Study 1 – Power and technology
Research evidence does not support the widespread use of intrapartum CTG monitoring, yet it continues to be widely used. Central fetal monitoring systems are becoming more commonplace, again without evidence of benefit. Given the design of central monitoring systems they also provide a means for surveillance of maternity clinicians as they work with birthing women.
This Doctoral research used Institutional Ethnography to critically examine the textual environment in maternity care. The findings identified the dominance of patriarchal obstetric knowledge paradigms and provided specific examples of how birthing women were considered to be risky and largely irrelevant to decision-making, the fetus was portrayed as precious and constantly at risk, and midwives were considered to be poorly informed and in need of supervision.
The frequent use of intrapartum CTG monitoring in a central monitoring system, and the intrusive behaviour of senior staff in response to perceived CTG abnormalities became logical given these assumptions. Diverting midwives’ attention away from the birthing woman to attend to the CTG monitoring system had the potential to undermine the safe provision of maternity care.
Small, K. A., Sidebotham, M., Fenwick, J., & Gamble, J. (2020, Sept). Intrapartum cardiotocograph monitoring and perinatal outcomes for women at risk: Literature review. Women and Birth, 33(5), 411-418.
Study 2 – Tools for scaling up Midwifery Continuity of Care
Policy makers, funders, health service managers, the midwifery profession, and maternity service users need tools to model the cost-benefit impact of midwifery continuity of care to enable the case for service re-design to be effective.
We have developed a Midwifery Model Estimator to help address this need. The Estimator is a custom-built interactive business-costing tool to enable scale-up of midwifery continuity of care models for use with health services in Australia.
It provides an analysis of the cost benefit achieved relative to the proportion of women provided with midwifery continuity of care. Local data is used to model potential cost savings for the health service using different scenarios.
Study 3 – Mapping access to Midwifery Continuity of Care for vulnerable mothers and babies
This study investigates using spatial mapping to develop a population health tool to measure access, outcomes and the impact of midwifery continuity of care for vulnerable and disadvantaged groups of mothers and babies compared with other maternity models.
Women from culturally and linguistically diverse backgrounds, Indigenous women, young women, women living in poverty, and women who reside in rural and remote locations are the focus of this study.
Study 4 – Health care accreditation and maternity services reform
Australia has a complex public and private maternity health system that provides care for childbearing women, their babies and families. We also have a well-established national health care accreditation system that is government funded, legislated, and mandated, with government action for unmet standards. Hospital accreditation is the main national safety and quality system in Australia.
However, there is a disconnect between the health care accreditation and the implementation of widespread access to continuity of midwifery care.
This program of work commenced with a scoping review of the literature investigating the issues related to hospital accreditation, in particular in the Australian healthcare system, and as it relates to driving health service re-organisation towards continuity of midwifery care. Next projects are being planned and we are seeking partners to progress this work.
Gamble, J., Browne, J & Creedy, DK. (2020). Hospital accreditation: Driving best outcomes through continuity of midwifery care? A scoping review. Women and Birth, In press.
Study 5 – Obstetricians and trauma
Trauma during childbirth, such as maternal death or severe injury to a baby, impacts not only the family but maternity staff, and may contribute to a range of psychological responses, including post-traumatic stress (PTSD). Furthermore, for some medical practitioners, subsequent trauma may include stress related to being reported to the medical board. Trauma exposure and PTSD has consequences for the mental health of the individual (including possible suicide) or leaving the workforce. Doctors with burnout, or mental health conditions including PTSD, may be less able to provide appropriate patient care. Little is known about the impact of birth trauma on the mental health of obstetricians in Australia and New Zealand. Our recent feasibility study found high levels of exposure to some type of birth trauma, and presence of current symptoms of traumatic stress. Over 40 percent reported significant post-traumatic growth. Thematic analysis revealed perceptions that ‘obstetricians experience substantial trauma’, a ‘culture of blame in obstetrics’, and only ‘some workplaces were supportive and safe’.
Publications: Walker, Gamble, Creedy, Ellwood. (2019). Impact of traumatic birth on Australian obstetricians: A pilot feasibility study. Australian and New Zealand Journal of Obstetrics and Gynaecology, 60(4), 555-560. https://doi.org/10.1111/ajo.13107
Study 6 – Birth places and spaces in Australia: An exploration of the motivations and experiences of women using unlicensed birth houses
While there are few unlicensed birth houses currently operating in Australia, out-of-hospital birth continues to remain an important aspect of maternity services for some women. Currently there is a scarcity of information on birth houses and these models are in the minority. This qualitative study explores women’s experiences and motivations for choosing maternity care through unregulated birth houses to gain greater understanding for the role these birth places and spaces have in contemporary maternity services in Australia.
Study 7 – Examining facilitators and barriers to access and use of publicly funded homebirth services in Australia
Access to integrated primary health maternity services for birth at home show marked variation in Australia. There is limited knowledge of specific factors that influence demand and uptake of these services in the public sector. This study examines childbearing women’s views of the access and entry requirements to publicly funded homebirth programs and services in Australian states and territories. It focuses on understanding the facilitators and barriers to access, uptake and expansion of homebirth services from women who use or seek to use these programs.
Study 8 – Midwives conceptualisation of intrapartum risk
Midwifery care is increasingly viewed as an inherently risky area. Organisational risk management and clinical governance has a significant impact on contemporary midwifery practice. Intrapartum risk amplification is often managed by inordinate surveillance and intervention. However, increasing the focus on risk management does not necessarily facilitate the safety of the woman and her baby and may introduce iatrogenic risk.
This doctoral research has utilised phenomenography to elicit the critical variation in the qualitatively different ways midwives conceptualise intrapartum risk. The findings identified that midwives conceptualise risk as the industrial nature of maternity care and that they are navigating a dichotomy of care, trying to facilitate physiology while working in a biomedical context. This is evidenced by increasing surveillance, technology and intervention which is used to mitigate litigation and scrutiny from the trans-disciplinary milieu. The birthing woman herself is understood as a risk due to her co-morbidities or by the relationship between the woman and the midwife. Cultural risk was also a significant conceptualisation, with midwives understanding that current birthing policies relating to First Peoples women posed a significant risk.
Study 9 – Women’s experiences of negotiating and using water immersion/birth to achieve a vaginal birth after caesarean section
For women who have had a previous caesarean section keeping subsequent labours normal and free of intervention are key factors that increase the likelihood of a vaginal birth. Water immersion during labour offers potential benefits for women wanting to have a vaginal birth after caesarean (VBAC), however, its use in this cohort of women remains contentious.
Using Grounded Theory methodology this study examines women’s experiences of negotiating and/or using water immersion for their VBAC. Water was perceived by the women as a valuable tool in facilitating a natural, normal labour and birth.
The professional discourse around the use of water immersion during labour and birth, for women with a history of a previous caesarean section, remains contested. The rhetoric of risk was commonly used to control and regulate women’s choices and bodies.
Breastfeeding impact: a five-paths approach
When mothers and babies discharge home from hospital feeding directly at the breast, it symbolises the quality of maternity care received during pregnancy, birth and early postnatal periods. This research program, the Pathways Approach to Breastfeeding, focusses on five key areas which are independently associated with feeding directly at the breast at hospital discharge.
Study 1 – Midwifery-led services and facilities: midwifery continuity of care: models of care for vulnerable families; health engagement; out-of-hospital birth.
Allen, J. et al. (2019). The impact of caseload midwifery compared to standard care on women’s perceptions of antenatal care quality: Survey results from the M@NGO randomised controlled trial for women of any risk. Birth: Issues in Perinatal Care, 46, 439-449. https://doi,org/10.1111/birt.12436
Kildea, S., Hickey, S., Barclay, L., Kruske, S., Nelson, C., Sherwood, J., Allen, J., et al. (2019). Implementing Birthing on Country services for Aboriginal and Torres Strait Islander families: RISE Framework. Women and Birth, 32(5), 466-475. https://doi.org/10.1016/j.wombi.2019.06.013
Allen, J., et al. (2017). The motivation and capacity to go ‘above and beyond’: Qualitative analysis of free-text survey responses in the M@NGO randomised controlled trial of caseload midwifery. Midwifery, 50, 148-156. https://doi.org/10.1016/j.wombi.2017.08.049
Tracy, S.K., Hartz, D.L., Tracy, M.B., Allen, J., et al. (2013). Caseload midwifery care versus standardmaternity care for women of any risk: M@NGO, a randomized controlled trial. The Lancet, 382(9906), 1723-1732. https://doi.org/10.1016/S0140-6736(13)61406-3
Study 2 – Spontaneous onset of labour at term: early labour care; informed decision-making around induction of labour; strategies to increase the term birth rate.
Allen, J., Jenkinson B., Tracy, S., Tracy, M., Hartz, D., Kildea, S. (2020). Women’s unmet needs in early labour: Qualitative analysis of free-text survey responses in the M@NGO trial of caseload midwifery. Midwifery, 88, 102751. https://doi.org/10.1016/j.midw.2020.102751
Williams, L., Jenkinson, B., Lee, N., Gao, Y., Allen, J., et al. (2020). Does introducing a dedicated early labour area improve birth outcomes? A pre-post intervention study. Women and Birth, 33(3), 259-264.https://doi.org/10.1016/j.wombi.2019.05.001
Allen, J., et al. (2016). How optimal caseload midwifery can modify predictors for preterm birth inyoung women: integrated findings from a mixed methods study. Midwifery, 41, 30-38. https://doi.org/10.1016/j.midw.2016.07.012
Study 3 – Non-pharmacological analgesia: warm water immersion and water birth.
Allen, J., Gao, Y., Dahlen, H., Reynolds, M., Beckmann, M., Cooper, C., & Kildea, S. (under review). Women with uncomplicated pregnancies who intend waterbirth, compared to non-waterbirth, at onset of second stage labour: a feasibility cohort study.
Study 4 – Spontaneous vaginal birth: hands-poised for birth; upright birth positions; and non-directed pushing.
Allen, J., Small, K., & Lee, N. (under review). The impact of the perineal bundle on Australian hospital midwifery practice: a critical thematic analysis.
Study 5 – Optimising mother-baby interaction: first hour after birth; skin-to-skin contact; and baby-led breastfeeding.
Allen, J., Parratt, J., Rolfe, M., Hastie, C., Sexton, A., & Fahy, K. (2019). Immediate, uninterrupted skin-to-skin contact and breastfeeding after birth: A cross-sectional electronic survey. Midwifery, 79, 102535. https://doi.org/10.1016/j.midw.2019.102535
O’Connor, M., Allen, J., et al. (2018). Predictors of breastfeeding exclusivity and duration in a hospital without Baby Friendly Hospital Initiative accreditation: A prospective cohort study. Women and Birth, 31(4),319-432.https://doi.org/10.1016/j.wombi.2017.10.013
Research by higher degree student projects:
Routine postdates induction of labour: critical discourse analysis – Primary Supervisor
Interventions to improve women’s experience of abortion care: mixed methods – Associate Supervisor
Shared decision-making in maternity care: mixed methods- Associate Supervisor
Lead: Dr Jyai Allen
Additional projects relevant to Practice Translation
Other projects and studies relevant to this program area include:
Study: Obstetricians and trauma