Preconception Care - Issues Paper

The evidence for the link between maternal risk factors (including smoking, obesity, alcohol use and maternal mental health) and perinatal morbidity and mortality rates among Australian women is clear. There is also a growing body of evidence that Indigenous women are significantly more likely than their non-Indigenous counterparts to be impacted by these risk factors. Risk factors originate from genetic, environmental and behavioural factors. In alignment with the Health and Social Policy Branch’s Strategic Plan, Healthy, Safe and Well, the purpose of this paper is to focus on those risk factors that have a behavioural element and can, therefore, be modified, or impacted by strategies to minimise associated harms. Smoking in pregnancy has been highlighted as the most significant preventable cause of morbidity and death among women and infants. The risk of smoking increases among Indigenous and other disadvantaged women. A combination of policy and social marketing interventions involving comprehensive bans on advertising and sponsorship, tobacco price increases, bans on smoking in work and public places, health warnings on packs, mass media, QUIT telephone coaching and monitoring by a physician have been found to be most effective. Trends in nutrition, physical activity and obesity suggest a need for greater awareness and education of women in their reproductive years, prior to conception. Given women who are overweight or obese at conception are at increased risk of excessive gestational weight gain, parenting education and the setting of weight management goals have had some traction in antenatal care, however, the success of such programs relies on regular attendance and health practitioner skill. Although targeted health promotion interventions have increased acceptance of the importance of a healthy diet and exercise, many health practitioners lack skills to manage the problem, and evidence of the efficacy of such interventions in achieving reductions in obesity at the population level is lacking. Aboriginal women are at increased risk of obesity and government support for culturally appropriate programs targeting lifestyle behaviours and supporting health eating and physical activity in local communities have the potential to impact positively. Alcohol consumption among young women and pregnant women in NSW represents a significant risk factor potentially impacting the unborn fetus. Whilst the proportion of women engaged in heavy drinking in pregnancy is low, the adverse outcomes (including FASD) of heavy gestational alcohol consumption and the lack of evidence around safe levels of consumption highlight the issue as a high public health priority. Mandatory labelling of alcohol products and training of health professionals have been proposed as best practice interventions, in combination with addressing issues of pricing and taxation and advocating abstinence from drinking during pregnancy. The estimated prevalence of harmful drinking in Indigenous populations is twice that of non-Indigenous populations and the normalisation of harmful consumption highlights the need to target Indigenous populations, Aboriginal Medical Services (AMS) and Aboriginal clinicians to give health practitioners the skills and resources needed to advocate for reduced alcohol consumption in pre-pregnancy. Key components of effective interventions targeting Aboriginal women and health practitioners in contact with women in preconception and pregnancy are interactive community-based education, culturally appropriate printed resources and ongoing community engagement. Maternal mental health issues are estimated to affect 10-15% of women in high income countries during the perinatal period. Policy frameworks in NSW reflect recognition of the need for greater awareness of maternal mental health and the requirement to integrate programs that provide support for women’s well-being in the antenatal and postnatal phase into policy, planning and delivery of health services. An evidence-based health home visiting program called Sustaining NSW Families, developed for the identification and treatment of women at risk of antenatal and postnatal depression, has been found to be effective as an early intervention tool. Factors impacting the health and well-being of Aboriginal people include spirituality, the relationship with family, land and culture and these factors are all intertwined. Programs targeting these women need to be culturally appropriate, driven by the community and run by a workforce who understands the psycho-social risks resulting from intergenerational trauma.Health and Social Policy Branch, NSW Ministry of Healt

Ethnicity or cultural group identity of pregnant women in Sydney, Australia: is country of birth a reliable proxy measure?

Background: Australia has one of the most ethnically and culturally diverse maternal populations in the world. Routinely few variables are recorded in clinical data or health research to capture this diversity. This paper explores and how pregnant women, Australian-born and overseas-born, respond to survey questions on ethnicity or a cultural group identity, and whether country of birth is a reliable proxy measure. Methods: Frequency tabulations and inductive qualitative analysis of data from two questions on country of birth, and identification with an ethnicity or cultural group from a larger survey of pregnant women attending public antenatal clinics across four hospitals in Sydney, Australia. Results: Responses varied widely among the 762 with 75 individual cultural groups or ethnicities and 68 countries of birth reported. For Australian-born women (n=293), 23% identified with a cultural group or ethnicity, and 77% did not. For overseas-born women (n=469), 44% identified with a cultural group or ethnicity and 56% did not. Responses were coded under five emerging themes. Conclusions: Ethnicity and cultural group identity are complex concepts; women across and within countries of birth identified differently. Over three quarters of Australian-born, and over half of over-seas born women, reported no ethnicity or cultural group identity, indicating country of birth is not a reliable measure for identifying diversity. Researchers should scrutinise research questions and data usage, policy makers consider the complexity of ethnicity or cultural group identity, and the limitations of a single variable measure to identify ethnically and culturally diverse pregnant women and deliver woman-centred care.NHMR

Women’s beliefs about the duration of pregnancy and the earliest gestational age to safely give birth.

Background: American evidence suggests women are not well informed about the optimal duration of pregnancy or the earliest time for safe birth. Similar evidence does not exist in Australia. Aims: To explore pregnant women’s beliefs about the duration of pregnancy and the earliest time for safe birth, and to compare the results with US data. Methods: A cross-sectional survey of pregnant women attending antenatal clinics at four public hospitals in Sydney, Australia, included collection of maternal and pregnancy characteristics, and two questions exploring women’s beliefs about the duration of pregnancy, and the earliest time for safe birth. Responses were grouped as: late preterm (34-36 weeks), early term (37-38 weeks), and full term (39-40 weeks). Results: Of 784 surveyed women, 52% chose 39-40 weeks as the duration of a full term pregnancy, while for the earliest time for safe birth, 10% chose 39-40 weeks and 57% chose 37-38 weeks. Some maternal characteristics were associated with women’s beliefs, including having a medical and/or pregnancy complication, country of birth, level of education, employment status, and attending a tertiary hospital. The associations were different for each question. In comparison with US studies, Australian women were more likely to choose later gestations for both the duration of pregnancy and the earliest time for safe birth. Conclusions: A significant proportion of Australian women believe that full term pregnancy and earliest time for safe birth occur before 39 weeks, suggesting opportunities for antenatal education.The authors would like to thank the women who participated in the survey, and acknowledge the contribution of the research midwives, Jill Milligan, Rachel Reid, Jocelyn Sedgley and Katrina White-Mathews, as well as Dr. Antonia Shand for assisting with participant recruitment. This work was supported by an Australian National Health and Medical Research Council (NHMRC) Centre for Research Excellence Grant (1001066). CLR is supported by an NHMRC Senior Research Fellowship (#APP1021025)

Testing a health research instrument to develop a statewide survey on maternity care

Partnerships between researchers and end users are an important strategy for research uptake in policy and practice. This paper describes how collaboration between an academic research organisation (the Kolling Institute) and a government performance reporting agency (the NSW Bureau of Health Information (BHI)), contributed to the development of a new statewide maternity care survey for NSW.NHMR

Are women birthing in New South Wales hospitals satisfied with their care?

Abstract Background Surveys of satisfaction with maternity care among Australian women have been conducted using overnight inpatient surveys and dedicated maternity surveys in a number of Australian states and territories, however to date no information on satisfaction with maternity care has been published for women birthing in New South Wales. The aim of this study was to investigate the effects of pregnancy and birth characteristics, hospital location and type of care provision on patient satisfaction with hospital care at the time of birth. Results Analysis of responses from 5,367 obstetric patients completing overnight patient surveys between 2007 and 2011 revealed three quarters of women were satisfied with care provided in hospital. Compared with women who had previously given birth, first-time mothers were more likely to recommend their birth hospital to friends and family (60.5% versus 56.4%; P<0.05), less likely to have experienced differing messages from staff (44.8% vs 59.4%; P<0.001), and less likely to feel they had received sufficient information about feeding (58.8% vs 65.0%; P<0.001) and caring for their babies (52.4% vs 65.2%; P<0.001). Women having a caesarean birth were more likely to have a negative experience of differing messages from doctors and nurses than women giving birth vaginally (52.7% vs 44.3%; P<0.001). While metropolitan women were more likely to rate their birth hospital positively (76.0% vs. 71.3%; P<0.05) than their rural counterparts, rural women tended to rate the care they received (68.1% vs. 63.4%; P<0.05), and doctors (70.7% vs 61.1%; P<0.05) and nurses (73.5% vs. 66.9%; P<0.001) more highly than metropolitan women. Conclusions The overall picture of maternity care satisfaction in New South Wales is a positive one, with three quarters of women satisfied with care. The differences in care ratings among some subgroups of women (for instance, by parity and rurality) may assist in targeting allocation of resources to improve maternity satisfaction. Further resources could be dedicated to ensuring consistency and amount of information provided, particularly to first-time mothers.Australian Research Council Future Fellowship (#FT120100069)

Women's views about the timing of birth

Background: Estimated date of birth (EDB) is used to guide clinical management of 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, it may be helpful to ask each woman how she would like to receive estimated timing of birth information.NHMR

Pre-notification letter type and response rate to a postal survey among women who have recently given birth

Background: Surveys are commonly used in health research to assess patient satisfaction with hospital care. Achieving an adequate response rate, in the face of declining trends over time, threatens the quality and reliability of survey results. This paper reports on a postal satisfaction survey conducted with women who had recently given birth, and explores the effect of two strategies on response rates. Methods: A sample of 2048 Australian women who had recently given birth were invited to participate in a postal survey about their recent experiences with maternity care. The study design included two different strategies intended to increase response rates: a randomised controlled trial testing two types of pre-notification letter (with or without the option of opting out of the survey), and a request for consent to link survey data with existing routinely collected health data (omitting the latter data items from the survey reduced survey length and participant burden). Results: The survey had an overall response rate of 46%. Women receiving the pre-notification letter with the option of opting out of the survey were more likely to actively decline to participate than women receiving the letter without this option, although the overall numbers of women were small (27 versus 12). Letter type was not significantly associated with the return of a completed survey. Among women who completed the survey, 97% gave consent to link their survey data with existing health data. Conclusions: Seeking consent for record linkage was highly acceptable to women who completed the survey, and represents an important strategy to add to the arsenal for designing and implementing effective surveys. In addition to aspects of survey design, future research should explore how to more effectively influence personal constructs that contribute to the decision to participate in surveys.NHMR

Supporting research translation through partnership

This paper provides a brief introduction to research translation in health care and three essential building blocks that support the process of using evidence to inform health policy and practice: partnerships, system readiness and diversity of evidence. We then describe a ‘live’ example of research translation currently underway between a research group and policy makers working together to support maternity care in NSW, and the important facilitating role of a shared knowledge broker.NSW Population Health and Health Services Research Support Program (PHHSRSP) gran

Woman-centred maternity care: what do women say? Protocol for a survey of women receiving maternity care in NSW

Background: Over the past decade or so, recommendations for improvements in maternity care have emphasised the importance of providing woman-centred care. Feedback from women about existing maternity services can help to identify whether services are currently meeting women’s needs. The present study aims to capture women’s expectations of, and experiences with maternity care, and to explore whether maternal and birth characteristics are associated with those experiences. Methods: A survey will be undertaken with a sample of approximately 2,000 women who have given birth over a 3-month period at seven public maternity units in two neighbouring health districts in New South Wales (NSW), Australia. The survey will be mailed out three-four months after birth. The study will also examine two strategies intended to increase survey response rates: use of two types of pre-notification letters, and request for consent from women to link survey responses with health information recorded at the time of birth. Data analysis will examine response rate, evidence of sample bias and effect of pre-notification letters; describe expectations and experiences with maternity care and associations with maternal and/or health characteristics; and where possible, compare results with maternity satisfaction data reported by others. Discussion: This study will provide, for the first time in NSW, comprehensive information about women’s expectations, experiences and satisfaction with maternity services in two local health districts. It will identify aspects of care that are meeting women’s needs, and areas where care and service provision may be improved in line with the aspirations of Towards Normal Birth. The survey tool may also prove to be appropriate for use by other health districts and/or state-wide.NHMR