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.
A number of projects have been completed or are currently underway, including:
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 Standard Set of Outcome Measures for Pregnancy and Childbirth consists of well-known measurement scales, relatively new scales, and discrete items which are believed to be important to women and may be useful in transforming healthcare within and across states, as well as countries, 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 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 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 – Impact of midwifery continuity of care beyond the time around birth
The benefits to women and newborns of continuity of midwifery care (caseload midwifery model) are well established however the focus of research to date has been on clinical outcomes around the time of birth. This study investigates outcomes beyond this period that may impact life-long health and are important to women.
Study 3 – 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 4 – 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 re-design these services
Using a co-design process the Logan Community Maternal and Child Health Hubs aimed to address the specific needs of women and families experiencing the greatest disadvantage in the City of Logan.
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 is undertaking a critical realist evaluation, in collaboration with Metro South Health Service partners, Health Consumers Queensland, Office of the Chief Nursing and Midwifery Office – Queensland Health and Logan Together to assess impact, sustainability and scalability of this innovative co-designed, 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.
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 (Duckett, Jorm, Moran, et al., 2018). 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 has 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.
Study 5 – Midwives and maternity reform
A motivated, well-educated midwifery workforce is a critical factor in the implementation of continuity of midwifery care models. This qualitative descriptive study explores the motivation, willingness and ability of midwives in Victoria to contribute to maternity services reform through working in and supporting continuity of midwifery practice models.
Study 6 – 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 with 32 obstetricians found that nearly all (n=31, 96.9%) had been exposed to some type of birth trauma. Three quarters had current symptoms of traumatic stress, one quarter had symptoms of burnout associated with the workplace, but over 40 percent reported significant posttraumatic 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, in press. https://doi.org/10.1111/ajo.13107
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. Focus on this primary outcome has led to the development of five key areas of research, each of which independently predict breastfeeding, and potentiate each other.
- Midwifery-led services and facilities includes research on midwifery continuity of care; models for vulnerable families; health engagement; birth centres; homebirth; and freestanding midwifery units.
- Spontaneous onset of labour at term includes research on early labour care; informed decision-making (e.g. breech, vaginal birth after caesarean section, twins, post-dates pregnancy); strategies to increase the term birth rate.
- Non-pharmacological analgesia includes research on warm water immersion and water birth; sterile water injection; professional labour support; and hypnosis during labour.
- Spontaneous vaginal birth includes research on hands-poised for birth; upright birth positions; and non-directed pushing.
- Optimising mother-baby interaction includes research on the first hour after birth; skin-to-skin contact; and baby-led breastfeeding.
Publications: 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
Lead: Dr Jyai Allen
Additional projects relevant to Practice Translation
Other projects and studies relevant to this program area include:
Study: Obstetricians and trauma