Judith Lumley

Neural tube defects arise during the development of the brain and spinal cord. The objective of this review was to assess the effects of increased consumption of folate or multivitamins on the prevalence of neural tube defects periconceptionally (that is before pregnancy and in the first two months of pregnancy). We searched the Cochrane Pregnancy and Childbirth Group trials register. Date of last search: April 2001. Randomised and quasi-randomised trials comparing periconceptional supplementation by multivitamins with placebo, folate with placebo, or multivitamins with folate; different dosages of multivitamins or folate; prepregnancy dietary advice and counselling in primary care settings to increase the consumption of folate-rich foods, or folate-fortified foods, with standard care; increased intensity of information provision with standard public health dissemination. Two reviewers assessed trial quality and extracted data. Four trials of supplementation involving 6425 women were included. The trials all addressed the question of supplementation and they were of variable quality. Periconceptional folate supplementation reduced the incidence of neural tube defects (relative risk 0.28, 95% confidence interval 0.13 to 0.58). Folate supplementation did not significantly increase miscarriage, ectopic pregnancy or stillbirth, although there was a possible increase in multiple gestation. Multivitamins alone were not associated with prevention of neural tube defects and did not produce additional preventive effects when given with folate.One dissemination trial, a community randomised trial, was identified involving six communities, matched in pairs, and where 1206 women of child-bearing age were interviewed following the dissemination intervention. This showed that the provision of printed material increased the awareness of the folate/neural tube defects association by 4%, (odds ratio 1.37, 95% confidence interval 1.33 to 1.42). Periconceptional folate supplementation has a strong protective effect against neural tube defects. Information about folate should be made more widely available throughout the health and education systems. Women whose fetuses or babies have neural tube defects should be advised of the risk of recurrence in a subsequent pregnancy and offered continuing folate supplementation. The benefits and risks of fortifying basic food stuffs, such as flour, with added folate remain unresolved.

Effective interventions to increase safety and wellbeing of mothers experiencing intimate partner violence (IPV) are scarce. As much attention is focussed on professional intervention, this study aimed to determine the effectiveness of non-professional mentor support in reducing IPV and depression among pregnant and recent mothers experiencing, or at risk of IPV.

Intimate partner violence (IPV) is prevalent globally, experienced by a significant minority of women in the early childbearing years and is harmful to the mental and physical health of women and children. There are very few studies with rigorous designs which have tested the effectiveness of IPV interventions to improve the health and wellbeing of abused women. Evidence for the separate benefit to victims of social support, advocacy and non-professional mentoring suggested that a combined model may reduce the levels of violence, the associated mental health damage and may increase a woman's health, safety and connection with her children. This paper describes the development, design and implementation of a trial of mentor mother support set in primary care, including baseline characteristics of participating women.

In Australia and internationally, there is concern about the growing proportion of women giving birth by caesarean section. There is evidence of increased risk of placenta accreta and percreta in subsequent pregnancies as well as decreased fertility; and significant resource implications. Randomised controlled trials (RCTs) of continuity of midwifery care have reported reduced caesareans and other interventions in labour, as well as increased maternal satisfaction, with no statistically significant differences in perinatal morbidity or mortality. RCTs conducted in the UK and in Australia have largely measured the effect of teams of care providers (commonly 6–12 midwives) with very few testing caseload (one-to-one) midwifery care. This study aims to determine whether caseload (one-to-one) midwifery care for women at low risk of medical complications decreases the proportion of women delivering by caesarean section compared with women receiving 'standard' care. This paper presents the trial protocol in detail.

Halfway through the 20th century, views on pain in labour encompassed almost everything from women's self-blame to blaming nurses, midwives, doctors or partners for 'bad experiences'. Soon after that, giving birth came to be seen – in some settings and by some caregivers – as a 'natural' and thus benign event which women could 'master'. In their recent systematic review of women's expectations and experiences of pain relief in labour, Joanne Lally, Madeleine Murtagh, Sheila Macphail, and Richard Thomson show that there is wide variation in women's expectations and knowledge about the first birth. This systematic review provides us with a strong basis for reflection and action.

Mastitis is one of the most common problems experienced by women who are breastfeeding. Mastitis is an inflammation of breast tissue, which may or may not result from infection. The aims of this paper are to compare rates of mastitis in primiparous women receiving public hospital care (standard or birth centre) and care in a co-located private hospital, and to use multivariate analysis to explore other factors related to mastitis.

In the 1980s there was substantial interest in early pregnancy and pre-pregnancy interventions to increase birth weight and reduce preterm birth. We developed an inter-pregnancy intervention, implemented in a randomised controlled trial, to be provided by midwives at home soon after women's first birth. MCH nurses invited women to take part during their home visit to new mothers. Women's contact details, with their permission, were passed to the study midwife. She had a randomisation schedule to which women's names were added before she met the women or their partners. All women recruited had a home visit from the study midwife with a discussion of their first pregnancy, labour and birth and the postpartum experience. Women in the intervention arm received in addition a pre-pregnancy intervention with discussion of social, health or lifestyle problems, preparation and timing for pregnancy, family history, rubella immunisation, referrals for health problems, and a reminder card. The primary outcome was defined as a birth weight difference in the second birth of 100 g (one-sided) in favour of the intervention. Additional data collected were gestational age, perinatal deaths and birth defects. Analyses used EPI-INFO and STATA. Intervention and comparison groups were comparable on socioeconomic factors, prior reproductive history and first birth outcomes. Infant birth weight in the second birth was lower (-97.4 g,)) among infants in the intervention arm. There were no significant differences between intervention and comparison arms in the proportion of women having a preterm birth, an infant with low birthweight, or an infant with a birth weight th percentile. There were more adverse outcomes in the intervention arm: ten births <32 weeks), compared with one in standard care, and more infants with a birth weight <2000 g, 16 compared with two in standard care As the primary outcome was envisaged to be either improved birth weight or no effect, the study was not designed to identify the alternative outcome with confidence. Despite widespread support for pre-pregnancy interventions to improve maternal and perinatal health, this first randomised controlled trial of a multi-component intervention provided at home, did not have a beneficial outcome.

Background: State-wide surveys of recent mothers conducted over the past decade in Victoria, one state of Australia, have identified that women are consistently less satisfied with the care they received in hospital following birth compared with other aspects of maternity care. Little is known of caregivers' perspectives on the provision ofhospital postnatal care: how care is organised and provided in different hospitals; what constrains the provision of postnatal care (apart from funding) and what initiatives are being undertaken to improve service delivery. A state-widereview of organisational structures and processes in relation to the provision of hospital postnatal care in Victoria was undertaken. This paper focuses on the impact of staffing issues on the provision of quality postnatal care from the perspective of care providers. Methods: A study of care providers from Victorian public hospitals that provide maternity services was undertaken. Datawere collected in two stages. Stage one: a structured questionnaire was sent to all public hospitals in Victoria that provided postnatal care (n = 73), exploring the structure and organisation of care (e.g. staffing, routine observations, policy framework and discharge planning). Stage two: 14 maternity units were selected and invited to participate in a more in-depth exploration of postnatal care. Thirty-eight key informant interviews were undertaken with midwives (including unit managers, associate unit managers and clinical midwives) and a medical practitioner from eachselected hospital. Results: Staffing was highlighted as a major factor impacting on the provision of quality postnatal care. There were significant issues associated with inadequate staff/patient ratios; staffing mix; patient mix; prioritisation of birth suites over postnatal units; and the use of non-permanent staff. Forty-three percent of hospitals reported having only midwives (i.e. no non-midwives) providing postnatal care. Staffing issues impact on hospitals' ability to provide continuity of care. Recruitment and retention of midwives are significant issues, particularly in rural areas. Conclusion: Staffing in postnatal wards is a challenging issue, and varies with hospital locality and model of care. Staff/patient ratios and recruitment of midwives in rural areas are the two areas that appear to have the greatest negative impact on staffing adequacy and provision of quality care. Future research on postnatal care provision should include consideration of any impact on staff and staffing.

Background: Despite high levels of breastfeeding initiation in Australia, only 47 percent of women are breastfeeding (exclusively or partially) six months later, with marked differences between social groups. It is important to identify women who are at increased risk of early cessation of breastfeeding. Methods: Data from the three arms of a randomised controlled trial were pooled and analysed as a cohort using logistic regression to identify which factors predicted women continuing to feed any breast milk at six months postpartum. The original trial included 981 primiparous women attending a public, tertiary, women's hospital in Melbourne, Australia in 1999–2001. The trial evaluated the effect of two mid-pregnancy educational interventions on breastfeeding initiation and duration. In the 889 women with six month outcomes available, neither intervention increased breastfeeding initiation nor duration compared to standard care. Independent variables were included in the predictive model based on the literature and discussion with peers and were each tested individually against the dependent variable (any breastfeeding at six months). Results: Thirty-three independent variables of interest were identified, of which 25 qualified for inclusion in the preliminary regression model; 764 observations had complete data available. Factors remaining in the final model that were positively associated with breastfeeding any breast milk at six months were: a very strong desire to breastfeed; having been breastfed oneself as a baby; being born in an Asian country; and older maternal age. There was an increasing association with increasing age. Factors negatively associated with feeding any breast milk at six months were: a woman having no intention to breastfeed six months or more; smoking 20 or more cigarettes per day pre-pregnancy; not attending childbirth education; maternal obesity; having self-reported depression in the six months after birth; and the baby receiving infant formula while in hospital. Conclusion: In addition to the factors commonly reported as being associated with breastfeeding in previous work, this study found a negative association between breastfeeding outcomes and giving babies infant formula in hospital, a high maternal body mass index, and self-reported maternal depression or anxiety in the six months after the baby was born. Interventions that seek to increase breastfeeding should consider focusing on women who wish to breastfeed but are at high risk of early discontinuation.