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For peer review onlyCharacteristics and changes in characteristics of women and babies admitted to Residential Parenting Services in

New South Wales, Australia in the first year following birth: A population based data linkage study 2000-2012

Journal: BMJ Open

Manuscript ID bmjopen-2019-030133

Article Type: Research

Date Submitted by the Author: 28-Feb-2019

Complete List of Authors: Dahlen, Hannah; Western Sydney UniversityThornton , Charlene ; Flinders University Faculty of Medicine Nursing and Health Sciences, College of Nursing and Health Sciences Fowler, Cathrine ; University of Technology Sydney, Tresillian Chair in Child and Family HealthMills, Robert; Tresillian Family Care CentresO'Loughlin, Grainne; Karitane Residential Family Care UnitSmit, Jenny; Tresillian Family Care CentresSchmied, V; Western Sydney University

Keywords: parenting, perinatal mental health, instrumental birth, caesarean section, birth intervention, data linkage

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For peer review only

1

Characteristics and changes in characteristics of women and babies admitted to Residential Parenting Services in New South Wales, Australia in the first year following birth: A population based data linkage study 2000-2012

Dahlen, H.G, Thornton, C, Fowler, C, Mills, R, O’Loughlin, G, Smit, J, Schmied, V.

Professor Hannah Dahlen RN, RM, BN (Hons), Grad Cert Mid (Pharm) MCommN, PhD, FACM (Corresponding Author)

Professor of Midwifery

Western Sydney University

School of Nursing and Midwifery

Locked Bag 1797

Penrith South NSW Australia 2751

[email protected]

Ingham Institute Liverpool Australia

Charlene Thornton BN, Grad.Dip.Mid, M Sc Med (Research), M Sc Med (Clin Epi), PhD

Associate Professor of Midwifery

College of Nursing and Health Sciences

Flinders University

[email protected]

Cathrine Fowler RN, RM PhD

Professor – Tresillian Chair in Child and Family Health, University of Technology, NSW Australia

Broadway 2007 NSW Australia

Tel: 61 2 0407942916

[email protected]

Robert Mills RN, RM, MPH, FAICD

Associate Professor of Industry, Faculty of Health, University of Technology Sydney CEO Tresillian Family Care Centres Locked Bag 1003 Campsie NSW 2194M: +61 477 721 775E: [email protected]

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Grainne O’Loughlin BSc. (Hons) Speech Therapy, MBA CEO\

Chief Executive Officer

Karitane PO Box 241 Villawood NSW 2163 M 61 2 438 814193 E [email protected]

Jenny Smit B Sc(Nursing), RN, RM, MPH, MBusTech, MForensicMH

Associate Professor of Industry, Faculty of Health, University Technology Sydney Director Clinical Services Tresillian Family Care Centres Locked Bag 1003 Campsie NSW 2194

M: +61 417 837 525E: [email protected]

Virginia Schmied RN, RM.PhD

Professor of Midwifery, School of Nursing and Midwifery



Locked Bag 1797

Penrith 2751 NSW Australia

Tel: 61 2 9 685 9505

[email protected]

Abstract

Objective: To examine the characteristics of women and babies admitted to the

Residential Parenting Services (RPS) of Tresillian and Karitane in the first year

following birth.

Design: A linked population data cohort study involving population-based surveillance

systems was undertaken for the years 2000-2011.

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Setting: New South Wales, Australia.

Participants: All women giving birth and babies born in NSW were compared to those

admitted to RPS.

Results: During the time period there were 1 097 762 births (2000-2012) and 32 071

admissions to RPS. Women in cohort 1: (those admitted to RPS) were older at the time

of birth, more likely to be admitted as a private patient at the time of birth, be born in

Australia and be having their first baby compared to women in cohort 2 (those not

admitted to a RPS). Women admitted to RPS experienced more birth intervention

(induction, instrumental birth, caesarean section, epidural and episiotomy), had more

multiple births and were more likely to have a male infant. Their babies were also more

likely to be resuscitated and have experienced birth trauma (particularly to the scalp).

These women were also more likely to have mental health disorders. Between 2000-

2012 the average age of women increased by nearly two years; their infants were older

on admission and women were less likely to smoke. Women were also less likely to be

Australian born. Over the time period there was a drop in the numbers of women

having a normal vaginal birth and an increase in women having an instrumental birth.

Conclusion: Women who access RPS in the first year after birth are more socially

advantaged and have higher birth intervention than those who do not. The rise in

women admitted to RPS (2000-2012) who have had instrumental births is intriguing as

overall rates did not increase.

Keywords: residential parenting services, early parenting, perinatal mental health,

caesarean section, early term birth, instrumental birth, data linkage

Strengths:

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The uniqueness of this study is in establishing the most comprehensive study

undertaken over more than a decade of all women and babies admitted to RPS in

NSW

Women who access RPS in the first year after birth are more socially advantaged

and have higher birth intervention than those who do not access RPS.

Changes over time show a significant rise in women admitted to RPS who have

had instrumental births

Limitations:

lack of maternal body mass index data which would enable further examination

of associated factors.

visits to general practitioners, community based and outpatient facilities are not

included in the datasets.

Funding statement

This research received an Australian Research Council Grant

PPI statement

A waiver of consent was obtained for the undertaking of this research with

consideration of the fact of the difficulty in obtaining consent considering the

retrospective nature of the study and the fact that only de-identified information was

recorded from the medical records reviewed

Competing interest statement

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Cathrine Fowler, Robert Mills, Grainne O'Loughlin and Jeanette Smit all work for the

organisations of Tresillian and Karitane and were partners in the project but they did not

analyse or interpret the data. An ARC Linkage grant was received for this work LP130100306

Introduction

Many parents experience difficulties with early parenting, in particular with

breastfeeding, settling an infant, especially if they cry excessively [1-4]. Sleep and

settling problems with infants are reported to be severe by over 30% of women in

Australian studies [5]. This can lead to maternal exhaustion and poorer mental and

physical health in women [6]. While parenting issues are of concern, they are often a

sign of maternal dysregulation as an outcome of maternal distress and mental illness[7].

The infant’s behaviour is frequently the reason for seeking professional assistance. If

left untreated physical and mental health problems can impact women and babies both

in the short and long term [8].

In Australia residential parenting services (RPS) such as Tresillian and Karitane (in New

South Wales -NSW) support parents experiencing parenting difficulties, such as feeding

and settling. Both baby and mother/father are admitted to these units. RPS are

identified as tertiary level services. They are funded as not-for-profit health affiliated or

government services. There is close alignment to the population-based child and family

health nursing service offered to all children and families following birth (similar to the

English health visiting service) and they follow a parent and infant centred approach to

the provision of care. In NSW (Australia’s most populace state) around 3,400 women

(3.5% of the birthing population) use the RPS of Tresillian (three RPS) and Karitane

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(two RPS) each year [9, 10]. Overall there are significant similarities between the two

services in NSW as there is often collaboration in the development of clinical guidelines.

In states such as Victoria around 5% of women are admitted to RPS [11]. Referrals to

these organisations come from all over NSW [12, 13]. The demand for RPS is high with

waiting lists reported between four-to-ten weeks in most states [14]. Less is known

about changes in the populations’ characteristics and reasons for seeking RPS care over

time.

Aim

The aim of this study is to examine the characteristics of a cohort of women and babies

admitted to RPS of Tresillian and Karitane in the first year following birth in NSW, as

well as examine changes in characteristics that have occurred over a decade.

Methods

Data sources

Birth data for the time period January 1st 2000 till December 31st 2012 of all births was

provided by the NSW Department of Health as recorded in the NSW Perinatal Data

Collection (PDC). This population based surveillance system contains maternal and

infant data on all births of greater than 400 grams birthweight or 20 weeks gestation.

Admission data following the birth were obtained from the NSW Admitted Patient Data

Collection (APDC) until 31st December 2013 to allow for 12 month follow up. This

collection records all admitted patient services provided by NSW Public Hospitals,

Public Psychiatric Hospitals, Public Multi-Purpose Services, Private Hospitals, and

Private Day Procedures Centres. The records of all infants and mothers who were

admitted to either of the two services were noted and linked to their pregnancy and

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birth details record (PDC) as well as subsequent hospital admission record (APDC)

utilising the common de-identified numeric identifier. Australian Bureau of Statistics

Socio-economic Indexes for Areas (SEIFA) codes were applied to the cohort in order to

establish socio-economic and education status [15]. The SEIFA indices are provided by

the Australian Bureau of Statistics and are calculated from National census information

collected in 2011 and published in 2013 based upon postcode and were applied to all

admissions. The indices are standardised with a lower index reflecting a lower level of

income or education level for that postcode or grouped postcodes.

Linkage of the datasets was conducted by the NSW Centre for Health Record Linkage

(CHeReL). The CHeReL utilises probabilistic data linkage techniques for these purposes

and de-identified datasets were provided for analysis. Probabilistic record linkage

software assigns a 'linkage weight' to pairs of records. For example, records that match

perfectly or nearly perfectly on first name, surname, date of birth and address have a

high linkage weight, and records that match only on date of birth have a low linkage

weight. If the linkage weight is high it is likely that the records truly match, and if the

linkage weight is low it is likely that the records are not truly a match. This technique

has been shown to have a false positive rate of 0.3% of records [16, 17].

Ethical approval was obtained from the NSW Population and Health Services Research

Ethics Committee, HREC/10/CIPHS/96. A waiver of consent was obtained for the

undertaking of this research with consideration of the fact of the difficulty in obtaining

consent considering the retrospective nature of the study and the fact that only de-

identified information was recorded from the medical records reviewed.

Subjects

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Maternal characteristics: age, parity, pre-existing (pre-pregnancy diabetes and chronic

hypertension) and pregnancy related medical conditions (pregnancy related diabetes

and hypertensive disorders of pregnancy and following birth), labour onset, delivery

type, pain relief utilised, perineal status. Labour onset was categorised as spontaneous,

induced (by means of prostaglandins, synthetic oxytocins and/or mechanic devices),

augmented (by means of synthetic oxytocins) or ‘No Labour’ (caesarean section before

labour) available from the PDC. Factors available for analysis in the APDC included

International Classification of Diseases V10 Australian Modification (ICD 10-AM) coding

[18] for admission diagnoses, co-morbidities, length of stay and frequency of admission.

Infant characteristics: included birthweight, gestation at birth, presentation and Apgar

Scores from the PDC and diagnostic codes for admission and co-morbidities.

Time periods were broken into three epochs to allow for changes in admission details

over time to be examined including 2000-2003, 2004-2008, 2009-2012.

Mothers and babies are admitted to the RPS for a variety of reasons including infant

based diagnoses: issues with settling, feeding and crying and/or maternal focussed

diagnoses: including anxiety, depression and parenting issues. Referral for admission is

made by the general practitioner, paediatrician, family and community health nurse as

well as self-referral. The two sites are independent from each other and both requested

they be named in the study.

Data analysis

The analyses were conducted between the two cohorts (women and babies admitted to

a RPS and those who were not) utilising contingency tables and results are reported as

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chi-square analyses. Continuous variables were compared with student t-tests when

normally distributed. Variables with missing data greater than 1.0% were excluded

from the analyses. Cells with n<5 were not included when conducting statistical

comparisons. Taking into account the size of the cohort and the number of analyses

undertaken, results were considered significant at the level p<0.01. Analysis was

undertaken with IBM SPSS v.23®

Ethics


Ethics Committee, Protocol No.2010/12/291. Approval was also granted by the RPS

services for release of de-identified data from each site.

Results

During the time period there were 1 097 762 births to 355 100 women in NSW. There

were 32 071 admissions to the RPS of Tresillian and Karitane in NSW.

Demographic and admission details

The demographic and admission details comparing the two cohorts (women and babies

who were admitted to RPS to those who were not) are displayed in Table 1. Women

admitted to RPS were on average two years older, more likely to be born in Australia

and almost half as likely to smoke. Nearly three quarters (72.5%) were >5th decile for

socio-economic advantage and disadvantage and over two thirds (67.2%) were >5th

decile for education and occupation. On average women stayed 4.4 days in the RPS and

this was slightly longer in Tresillian RPS. Women admitted to RPS were more likely to

have a multiple birth and be primiparous. While the vast majority of women were

admitted for one baby, some had several admissions for the same child and some

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women had admissions for subsequent children during the time period (2000-2012)

(Table 1).

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NSW

All women n=355 100

All babies n=1 097 762

Both facilities

All women n=32 071

All babies n=33 035

Karitane

n= 6651 (mothers)

n= 6663 (babies)

Tresillian

n=26 340 (mothers)

n=26 372 (babies)

Age

Mother

Baby

Mean 30.4 (SD 5.60)

Range 12-54

Mean 32.2 (SD 5.36)

Range 11 – 54

Median 228 days

Range 3 days – 4 years 206 days

Mean 31.6 (SD 5.25)

Range 13-51

Median 243 days


Mean 32.4 (SD 5.37)

Range 11-54

Median 227 days

Range 3 days-3 years 117 days

Smoking 13.9% 7.4% 7.2% 7.4%

Australian born 70.6% 78.1% 73.8% 79.2%

SEIFA (>5th decile for index of socio-economic advantage & disadvantage

55.4% 72.5% 58.8% 75.7%

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SEIFA (>5th decile for index of education & occupation)

51.8% 67.2% 57.9% 69.4%

Length of stay in RPS Mean 4.4 (SD 1.35)

Range 0-29

Mean 4.1 (SD 1.47)

Range 1-16

Mean 4.4 (SD 1.32)

Range 0-29

Discharge type

Standard

Own risk

99.8%

0.2%

99.3%

0.7%

99.9%

0.1%

Plurality

Singletons

Twins

Triplets

Quads

1 080 541 (98.5%)

16 892 (1.5%)

317 (0.03%)

12 (0.001%)

31 294 (94.7%)

1698 (5.1%)

40 (0.13%)

3 (0.0095)

6359 (95.4%)

298 (4.5%)

6 (0.09%)

0 (0.0%)

24 935 (94.6%)

1400 (5.3%)

34 (0.13%)

3 (0.01%)

Parity

Primiparous

Multiparous

42.1%

57.8%

62.8%

37.2%

61.1%

38.9%

63.2%

36.8%

No. of admissions (mothers with different babies)

1- 23 595

2 - 9076

1 - 4426

2 - 2141

1 – 19 169

2 - 6935

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Table 1 demographic and admission details

3 - 331

4 - 363

5 - 1

3 - 84

4 – 12

5 - 0

3 - 247

4 - 20

5 - 1

No. of admissions (mothers with same baby)

1 – 32 991

2 - 18

1 – 6651

2 - 6

1 – 26 340

2 - 16

Health Insurance status

Public

Private health insurance

Other

17 214 (52.1%)

15 799 (47.8%)

22 (0.1%)

3305 (49.6%)

3357 (50.1%)

1 (0.3%)

12 494 (47.4%)

13 857 (52.5%)

21 (0.1%)

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Birth and neonatal outcomes

The majority of women admitted to RPS had their babies in hospital, as is the case with

the rest of the NSW population. Substantially fewer women who were admitted to RPS

had a normal vaginal birth and more had an instrumental birth or caesarean section,

induction of labour, epidural or episiotomy compared to women not admitted to RPS.

There were no major differences in the incidence of hypertensive disease of pregnancy

and diabetes in women who were admitted to RPS. More women who were admitted to

the RPS had male babies. Babies were more likely to have been born at 37 and 38 weeks

gestation and less likely to be born over 40 weeks compared to babies who did not get

admitted to a RPS (Fig 1). Neonatal outcomes at birth tended to be worse for babies of

women admitted to RPS, with more SCN/NICU admissions and resuscitation at birth.

Birth trauma was also examined (Figure 2) and women admitted to RPS were more

likely to have given birth to a neonate who suffered scalp trauma.

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Table 2 Birth and neonatal outcomes

NSW

All women n=355 100


Both facilities

All women n=32 071

All babies n=33 035

Karitane

n=6663 (mothers)

n=6651 (babies)

Tresillian

n=26 372 (mothers)

n=26 340 (babies)

Place of birth

Hospital

Birth centre

Home Birth

Born before arrival

96.8%

2.5%

0.2%

0.5%

96.9%

2.8%

0.1%

0.2%

96.7%

2.7%

0.1%

0.1%

96.9%

2.8%

0.1%

0.2%

Place of birth

Public hospital

Private Hospital

Other

59.2%

36.1%

4.6%

49.5%

50.5%

0.0%

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Type of delivery

Vaginal

Forceps

Vacuum extraction

Vaginal breech

Caesarean section

Elective

Emergency

60.5%

3.6%

7.0%

0.6%

28.3%

16.3%

12.0%

48.9%

5.7%

9.9%

0.7%

34.8%

18.9%

15.9%

51.9%

5.8%

9.9%

0.6%

32.4%

18.1%

14.3%

48.1%

5.1%

9.8%

0.8%

35.4%

19.1%

16.3%

Episiotomy 11.6% 15.2% 15.8% 15.0%

Labour induced 25.1% 27.9% 27.2% 28.0%

Pain relief

None

Epidural

15.1%

25.4%

9.4%

38.5%

8.9%

36.4%

9.5%

39.0%

Hypertensive Disorders of Pregnancy

6.8% 8.3% 7.2% 8.6%

Diabetes 5.3% 4.9% 5.6% 4.7%

Baby sex male 51.4% 55.4% 54.6% 55.6%

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*means and standard deviations

Gestation at delivery 38.9 (2.20)* 38.8 (2.10)* 38.8 (2.10)* 38.7 (2.10)*

Birthweight 3369.5 (602.80)* 3309.4 (615.79)* 3310.9 (617.75)* 3303.1 (607.99)*

Apgar <7 2.1% 1.4% 1.6% 1.4%

Admitted SCN/NICU 15.6% 20.1% 19.5% 20.3%

Neonatal resuscitation (any form)

38.5% 43.8% 41.5% 44.4%

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Figure 1. Gestational age at birth comparison between babies admitted to

residential parenting services and those not admitted

Figure 2. Birth trauma as coded on birth admission for babies who enter

residential parenting services as compared to all other babies

Common ICD 10 codes for babies and mothers admitted to RPS

The most common ICD 10 codes recorded for babies were sleep, crying infant and

feeding disorders. Tresillian services were most likely to use the code R68.1

(nonspecific symptoms peculiar to infancy-excessive crying, irritable infant) (98.7%)

and Karitane were more likely to use F51.9/F51.2 (nonorganic sleep disorder

unspecified/ nonorganic disorder of the sleep wake cycle) (30.9%) (Table 3 and 4).

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Table 3: The seven most commonly recorded ICD-10-AM code for babies at Karitane grouped

Issue ICD-10-AM codes % of n=6651

Description

Sleep F51.9/F51.2 30.9% nonorganic sleep disorder unspecified/ nonorganic disorder of the sleep wake cycle

Crying R68.1 17.5% nonspecific symptoms peculiar to infancy-excessive crying, irritable infant

Feeding P92.2/P92.3/P92.4/

P92.5/P92.8/P93.9/R63.3

14.2% feeding difficulties and mismanagement/ neonatal difficulty at feeding at breast/ other feeding problems of newborn/slow feeding of newborn/ underfeeding of newborn /feeding problem of newborn not specified

Reflux K21.0/K21.9 11.7% GO reflux disease without oesophagitis/GO reflux disease with oesophagitis

Appearance

/behaviour

R46.8 8.7% other signs and symptoms involving appearance and behaviour

Psychiatric F93.0/F93.3/F51.0/F91.8/F93.2 5.6% separation anxiety disorder of childhood/ sibling rivalry disorder /Nonorganic insomnia/other conduct disorder/ social anxiety disorder of childhood

Social/other Z76.2/Z76.4 3.2% health supervision and care of others healthy infant and child - adverse socioeconomic circumstances, awaiting foster or adoptive placement, maternal illness, no of children at home preventing or interfering with normal care/ other boarder in health care facility

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Table 4: The seven most commonly recorded ICD-10-AM codes for babies at Tresillian grouped

Issue ICD-10-AM codes % of n=26 340 Description


Sleeping F51.2/G47.2/G47.9/ G47.0/ G47.8/ G47.1

6.7% nonorganic disorder of the sleep wake cycle/disorders of the sleep wake cycle/ sleep disorder unspecified/ other sleep disorders/ disorders of initiating and maintaining sleep/ disorders of excessive somnolence

Feeding R63.3/ F98.2/ P92.5/ P92.8/P92.9

6.3% feeding difficulties and mismanagement/ feeding disorder on infancy and childhood/ neonatal difficulty at feeding at breast/ other feeding problems of newborn/ feeding problem of newborn not specified

Development R62.0/R62.8/R62.9/F80.9 <1% delayed milestone /other lack of expected physiological development/lack of expected normal physiological development/ developmental disorder of speech and language

Psychiatric F84.0/F91.8/ F91.9/ F93.0/ F68.1 /F41.9/F43.2/F51.4/ F63.3/ F91.3

<1% Childhood autism/other conduct disorder/ conduct disorder unspecified/ separation anxiety disorder of childhood/factitious disorder/Anxiety disorder unspecified/PTSD/ sleep terrors/ trichotillomania/ oppositional defiant disorder

Reflux K21.9 <1% GO reflux disease without oesophagitis

Social/other Z76.2/Z76.8 <1% persons encountering health services in unspecified circumstances /health supervision and care of others healthy infant and child - adverse socioeconomic circumstances, awaiting foster or adoptive placement

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The most common ICD 10 codes recorded for women when combined were

malaise/fatigue and mental health disorders followed by feeding issues. However,

Tresillian was most likely to record social/other reasons for admission (Table 5 and 6).

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Table 5: The six most commonly recorded ICD-10-AM codes for mothers at Karitane grouped

Issue ICD-10-AM codes % of n=6663 DescriptionMalaise R53 37.9% malaise and fatiguePsychiatric F53.0/ F43.2/

F32.21/ F41.2/ F41.1/ F32.20/ F32.9/ F32.90/ F41.9/ F32.91/ F34.1/ F32.2/ F43.0/ F32.11

16.8% mild mental and behavioural disorders associated with the puerperium not elsewhere classified/ adjustment disorders/ Severe depressive episode without psychotic symptoms, arising in the postnatal period/ mixed anxiety and depressive disorder/ generalised anxiety disorder/ Severe depressive episode without psychotic symptoms, not specified as arising in the postnatal period/ depressive episode unspecified/ Depressive episode, unspecified, not specified as arising in the postnatal period/ anxiety disorder unspecified/ Depressive episode, unspecified, arising in the postnatal period/ dysthymia/ severe depressive episode without psychotic symptoms/ acute stress reaction/ Moderate depressive episode, arising in the postnatal period

Feeding Z39.1/ O92.50/ O92.41/ O92.11/ O92.71/ O92.10

3.7% care and examination of lactating mother/ Suppressed lactation, without mention of attachment difficulty/ Hypogalactia, with mention of attachment difficulty/ Cracked nipple associated with childbirth, with mention of attachment difficulty/ Other and unspecified disorders of lactation, with mention of attachment difficulty/ Cracked nipple associated with childbirth, without mention of attachment difficulty

Social/other Z76.8/ Z60.1/ Z63.0/ Z63.2/ Z63.7

3.5% persons encountering health services in other specified circumstances/ atypical parenting situation/ problems in relationship with spouse or partner/ inadequate family support/ other stressful life events affecting family and household

Sleep G47.0 3.2% disorders of initiating and maintaining sleepMultiparity Z64.1 1.1% problems related to multiparity

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Table 6: The five most commonly recorded ICD-10-AM codes for mothers at Tresillian grouped

Issue ICD-10-AM codes % of n=26 372 DescriptionSocial/other Z76.8/ Z60.8/

Z63.046.0% persons encountering health services in other specified circumstances/

other problems related to social environment/ problems in relationship with spouse or partner

Psychiatric F43.2/ F41.9/ F53.0/ F32.90/ F43.9/ F32.01/ F43.8/ F41.1/ F32.91/ F43.1/ F41.2/ F32.20/ F32.00/ F32.9/ F31.9/ F41.0/ F32.21/ F43.0/ R45.81

42.7% adjustment disorders/ anxiety disorder unspecified/ mild mental and behavioural disorders associated with the puerperium not elsewhere classified/ Depressive episode, unspecified, not specified as arising in the postnatal period/ reaction to severe stress unspecified/ Mild depressive episode, arising in the postnatal period/ other reactions to severe stress/ generalised anxiety disorder/ Depressive episode, unspecified, arising in the postnatal period/ PTSD/ mixed anxiety and depressive disorder/ Severe depressive episode without psychotic symptoms, not specified as arising in the postnatal period/ Mild depressive episode, not specified as arising in the postnatal period/ depressive episode unspecified/ bipolar affective disorders unspecified/ panic disorder episodic paroxysmal anxiety/ Severe depressive episode without psychotic symptoms, arising in the postnatal period/ acute stress reaction/ suicidal ideation

Malaise R53 30.8% malaise and fatigueFeeding Z39.1/ R63.3 <1% care and examination of lactating mother/ feeding difficulties and

mismanagementMultiparity Z64.1 <1% problems related to multiparity

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Trends over time of characteristics of women using RPS

The trends over time divided into three epochs were examined regarding the

characteristics of women admitted to RPS. Women admitted to RPS were significantly

older towards the end of the third time period when compared to the first when they

gave birth and their babies were older at admission between the two epochs. The rate of

women who were smoking had more than halved over the same time period. We also

found that women admitted were much less likely to have had a normal vaginal birth

and much more likely to have an instrumental birth in the last time period compared to

the first. Babies admitted to RPS were also less likely to have been admitted to

SCN/NICU (Table 7)

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2000-2003 2004-2008 2009-2012 p (epoch 1 compared to epoch 3)Maternal age years (Mean and SD) 30.3 (5.66) 30.9 (5.85) 32.0 (6.13) <0.001Infant age days (Median and IQ range) 97 (0-224) 140 (13-267) 167 (40-294) <0.001Smoking 13.6% 8.5% 5.4% <0.001Australian born 76.9% 78.7% 75.6% <0.001Hypertension 10.6% 10.4% 11.7% 0.54Diabetes 4.9% 5.7% 5.0% 0.45PluralitySingletonsMultiples

93.8%5.2%

94.7%5.3%

94.9%5.1%

0.45

ParityPrimiparousMultiparous

63.2%36.8%

63.0%37.0%

63.0%37.0%

0.76

Place of birth **HospitalBirth centreHome BirthBorn before arrival

96.9%2.8%0.1%0.2%

96.8%2.7%0.1%0.4%

96.9%2.8%0.1%0.2%

Place of birthPublic hospitalPrivate hospital

33.4%66.4%

35.1%64.9%

34.8%65.2%

0.54

Type of birthVaginalInstrumentalCaesarean section

52.5%17.2%30.3%

45.1%18.4%36.4%

41.6%23.3%35.0%

<0.001

Gestation (weeks)* 38.5 38.5 38.6 1.00Admitted to SCN/NICU 26.6% 24.5% 20.9% <0.001*calculated from last menstrual cycle or earliest ultrasound undertaken **cell count<5 statistics unable to be calculated

Table 7: Trends over time of characteristics of women using RPS (n=32 071 women, 33 035 infants)

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Discussion

This is the largest study to date examining the characteristics of all women and babies

admitted to RPS in NSW over more than a decade. Women who access RPS in the first

year after birth are more socially advantaged, have higher rates of birth intervention

and their babies have more neonatal complications than those who do not access RPS.

Sleeping, crying and feeding issues are the main reasons these babies are admitted to

RPS.

Sociodemographic differences in women who attend RPS and those who don’t

We found in this study that the women who attend RPS in NSW in the year following

birth were more socially advantaged than those not admitted. The women were slightly

older and the average age increased over the decade of the study reflecting both

Australian and international trends [19]. The women were also more likely to be born in

Australia but this declined over the decade which is also reflective of changing

demographics in NSW [20, 21]. Women attending RPS were also more likely to be a

private patient and more likely to be having their first baby or have had twins or

triplets. We also found the SEFA index was higher amongst women admitted which

correlates with the other characteristics described above. Other indications of social

advantage in the RPS population are the fact they are nearly half as likely to smoke

compared to women who do not attend RPS. In previous studies we found that women

who have private health cover and give birth in private hospitals tend to be more

socially advantaged and were much more likely to have their labour induced and much

less likely to have a normal vaginal birth without intervention [22]. This was also the

case in this study. Previous research has shown that women who attend RPS appear to

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be more socioeconomically advantaged and more likely to have a university education

with a professional or semi-professional occupation [11].

Even though these women are identified as socially and economically advantaged they

may still lack the social support necessary to develop the confidence in their ability to

parent while adjusting to the parenting role and changes in lifestyle that occurs with

motherhood [23]. Social isolation or perceived lack of social support has a significant

impact on parenting [24] . Social support from partner, family and friends appeared to

be the most significant in assisting mothers develop maternal competence and lowering

anxiety. Importantly, not all social support is helpful for mothers [24]. Attending to the

social support needs of mothers is crucial in reducing the risk or managing maternal

depression and anxiety [25] and also postpartum Post Traumatic Stress Disorder

(PTSD) [26] .

The fact that more socioeconomically advantaged women access RPS raises questions

about the disparity between them and women from socioeconomically disadvantaged

groups. Removing any existing institutional or other barriers to accessing RPS needs to

be prioritised, though with services already over capacity it is difficult to know how this

need could be met. Some of the barriers for women from lower socioeconomic

backgrounds may include: poor levels of health literacy, RPS service location, and a lack

of knowledge and misinformation about services [27] .

Birth intervention

It was clear in this study that more women in the RPS group had experienced an

intervention during the birth (induction of labour, instrumental birth, caesarean

section, episiotomy, epidural) and were significantly less likely to have a normal birth.

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Their babies were more likely to be preterm or early term as well and this was partly to

do with the fact they were also more likely to have multiple births. The babies were also

more likely to have been resuscitated and admitted to a SCN/NICU following their birth.

These higher intervention rates may have been due to increased complexity in the

pregnancy (also associated with older maternal age)[19], though there was no evidence

of a higher incidence of diabetes or hypertension. Again this has been shown to be

associated with women who are socially advantaged and have private obstetric care in

Australia [28], with evidence of more morbidity for babies as a result, especially scalp

trauma [22], which again was demonstrated in this study.

Intervention during birth has increased in much of the world (in developed and many

developing countries) in the past 20 years [22]. Both late preterm (34-36 weeks) and

early term (37-38 weeks) births [29] have also increased over the past decade leading

to increased risk of jaundice [30] and feeding difficulties [31]. In another Australian

study the authors found that even among low-risk women with no/minimal birth

intervention, there was a significantly increased risk of the baby going to SCN/NICU

when the baby was 37 weeks’ gestation at the time of birth [32], remaining significant

for low risk primiparas having a baby at 38 weeks gestation. The fetal brain goes

through a rapid increase in mass and nerve growth in the final weeks of gestation [33]

with recent research showing planned early term birth is independently associated with

poor child development and this is increased more for surgical modes of birth [34].

Infants born prematurely, small for gestational age (SGA) or with health problems are

reported to be less attentive, difficult to sooth and more likely to have feeding

difficulties [35], and their atypical behaviour makes it difficult for parents to read their

cues and respond appropriately [36]. Mothers of low birth weight (LBW) infants report

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more stress related to care of their infants compared with mothers of full-term infants

[35, 37, 38] and highly stressed parents of preterm infants are less sensitive and more

controlling than mothers of full-term infants in dyadic play, with possible long lasting

effects on mother-child interactional behaviour [39]. Studies also indicate that parents

of small for gestational age (SGA) infants report their infant as being more fearful and

negatively reactive compared to infants born appropriate for gestational age [40] and

that mothers have difficulty in reciprocal play with an infant born SGA and their

capacity to play with their infant moderates the relationship between infant mental

development at 12 months of age [41].

It is particularly interesting to note that over time the numbers of women admitted to

RPS who had an instrumental birth has increased. There has been increasing attention

in the media of late in Australia about maternal trauma (physical and mental) following

instrumental births [42] (particularly forceps) [43]. Women can be affected both

physically and psychologically, as well as babies [22, 44]. Instrumental and caesarean

delivery have been found to exert a negative impact on the first postnatal contact

between mother and baby with persistent adverse maternal emotional health correlates

persisting until eight months postpartum [45]. A large Australian postal survey of

women eight to nine months following birth found one of the factors associated with

increased chance of depression were the mothers inability to hold the baby after birth

[46]. Taking a very different approach, Swain et al. (2008) used magnetic resonance

imaging on the maternal brain 2-4 weeks following the birth to ascertain if there were

any differences in response to the cry of their baby following vaginal birth or caesarean

section [47]. They found women who had a vaginal birth had significantly more

responsive brain patterns than women who had a caesarean section. The clinical

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significance of this on parenting is unknown. Starting life with birth trauma and trying

to mother with physical and psychological trauma is not ideal and may explain the

apparent trend in more women going to RPS who have had caesareans and

instrumental birth. However, while caesarean section has increased during this time

period there was minimal change in the incidence of instrumental birth in NSW, so it is

interesting to see this change in those who are seeking RPS. It could be possible

practitioners are now less skilful with instruments, such as forceps, due to the increased

use of vacuum delivery and this may be leading to increased maternal damage. More

research is needed to unpick this intriguing observation. Other studies we have

undertaken have shown the high rate of severe perineal trauma with instrumental birth

[21]. In another study we undertook looking at the medical records of women seeking

RPS, we found caesarean section and forceps were both identified as contributing to

birth trauma [48].

The impact of birthing practices on the newborn and early mothering are not

insignificant [49]. Intrapartum synthetic oxytocin, for example, may disturb sucking and

breastfeeding duration in the newborn [50], with animal research showing lasting

effects on attachment, social interaction, feeding and sexual behaviour [51]. Short and

long term impact of mode of birth on the infant are also concerning indicating that

vaginal birth may initiate important physiological trajectories that have implications for

children and later on for adult health [52]. Unmedicated newborns are more aroused

immediately following the birth [53] and able to breastfeed without assistance if given

skin to skin contact and freedom from intrusive procedures [54, 55]. Following

caesarean section there is a significantly longer period of time compared to a normal

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vaginal birth before a mother touches and holds her newborn [56] and this impacts on

early breastfeeding[57].

In Australia, many women experience significant physical and psychological distress in

the year following birth and this can be increased with the use of obstetric

interventions. In the first six to seven months following birth, a large Victorian study

found 94% of women reported one or more health problems, with tiredness and

backache amongst the most commonly reported [58]. Compared with women who had

spontaneous vaginal births, women who had instrumental births reported more

physical health problems [58]. Some studies have shown the resolution of symptoms

such as exhaustion, backache, lack of sleep associated with baby crying and

perineal/pelvic floor morbidities between 8 and 24 weeks postpartum, but no

significant changes in headache/migraines, sexual problems and depression over the

first six months [59]. Longitudinal studies in Europe identified that symptoms such as

backache, anxiety and extreme tiredness are higher at 12 months than at 5 months

following childbirth, showing certain symptoms may increase over time, not decrease

[60]. Maternal emotional wellbeing is linked to physical health in the postnatal period. A

recent review on the literature on postnatal PTSD showed operative delivery

(caesarean section/instrumental birth) were both risk factors for developing PTSD

following the birth [26].

Sleeping crying and feeding difficulties main reasons for admission to RPS

Administrative data indicate that the most common admissions to RPS relate to infant

feeding and sleep and settling concerns [61-63]. The most common ICD 10 codes

recorded for babies admitted to RPS were sleep, crying and feeding disorders. The

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services used more frequently, such as R68.1 (nonspecific symptoms peculiar to

infancy-excessive crying, irritable infant) (98.7%) or F51.9/F51.2 (nonorganic sleep

disorder unspecified/ nonorganic disorder of the sleep wake cycle), show the

dominance of the three main factors (sleep, crying and feeding).

A recent study identifies a link between infant sleep problems and maternal depression

and anxiety [64]. Importantly, maternal-and-infant sleep behaviour is bidirectional in

nature [7] . For example, maternal sleep issues may be in response to infant behaviour

or the infant’s behaviour could be in response to the mother’s depression and anxiety

[7]. Field (2017) advises that most of the protective or risk factors associated with

infant sleep problems relate to parental management activities [65]. This confirms the

necessity to focus on both the mother’s mental health and the infant’s behaviour in any

intervention. A residential parenting unit is able to provide such holistic approaches to

working with mothers (parents) and their infants.

Of significance, for infant sleep and behavioural problems is the high incidence of

gastroesophageal reflux/disease (GOR/GORD) reported in babies admitted to RPS in

NSW (36%) and also the fact that the incidence remains at higher levels for longer

periods of time compared to those not admitted to RPS [66]. We also found maternal

mental health issues along with birth intervention and preterm and early term infants

was a major contributor to a label of GOR/GORD [66].

Limitations

This paper examines admissions to hospitals and day stay facilities only and therefore is

limited by the fact that visits to general practitioners, community based and outpatient

facilities are not included in the datasets. This paper only presents simple data analyses

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which do not include any adjustment or stratification. This methodology was utilised

due to the absence of data not included in the PDC and APDC which have been shown

previously to influence health outcomes, such as body mass index and whether a

diagnosis was new or pre-existing that admission.

It is not possible to draw a direct link between higher rates of intervention during the

birth and increased likelihood of having an admission to a RPS as other factors such as

having higher socio-economic and education levels that comes with social advantage

could lead to an increased uptake of services and these women are also more likely to

receive private obstetric care which is also associated with increased intervention. The

variations in the psychiatric diagnoses of the women accessing RPS may also be an

association that is not directly linked and further research is needed to confirm this.

Conclusion


admitted to RPS in NSW over 12 years. Women who access RPS in the first year after

birth are more socially advantaged, have higher rates of birth intervention and their

babies have more neonatal complications than those who do not access RPS. Sleeping,

crying and feeding issues are the main reasons these babies are admitted to RPS.

Contributors:

Hannah Dahlen formulated the study with Virginia Schmied and Cathrine Fowler. Charlene Thornton analysed the data. Robert Mills, Grainne O’Loughlin and Jenny Smit assisted in writing of the paper and proofing.

Funding

This paper reports on data collected in a larger Australian Research Council Linkage

grant LP130100306 that examined the clinical and demographic characteristics, trends,

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service needs and co-admissions to residential services of Tresillian and Karitane in

NSW from 2000-2012

Data Sharing statement:

We do not have ethics approval to share data.

Competing interests: Nil declared. All authors have completed the ICMJE uniform disclosure form.

Acknowledgments

We would like to thank Tresillian and Karitane for their partnership in this study and

their collegial support which was always warm and responsive. We would also like

thank the NSW for Health Record Linkage (CHeReL) for Linkage of the datasets.

References

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55. Righard L. How do newborns find their mother’s breast? . Birth. 1995;22:174–5.56. Fisher J, Astbury J, Smith A. Adverse psychological impact of operative obstetric interventions: a prospective study. Aust NZ J Psychiatry 1997;31:728–38.57. Prior E, Santhakumaran S, Gale C, Philipps LH, Modi N, Hyde MJ. Breastfeeding after ceasrean delivery: a systematic review and meta-analysis of world literature. American Journal of Clinical Nutrition 2012;Online ISSN: 1938-3207.58. Brown S, Lumley J. Maternal health after childbirth: results of an Australian population survey. British Journal of Obstetrics and Gynaecology. 1998;105:156-61.59. Thompson JF, Roberts CL, Currie M, Ellwood DA. Prevalence and Persistence of Health Problems After Childbirth: Associations with Parity and Method of Birth. Birth. 2002;29(2):83-94.60. Saurel-Cubizolles MJ, Romito P, Lelong N, Ancel PY. Women's health after childbirth: a longitudinal study in France and Italy. BJOG. 2000;107(10):1202-9.61. Fisher JRW, Rowe HJ, Hammarberg K. Admission of women, with their infants, for psychological and psychiatric causes in Victoria, Australia. Australian and New Zealand Journal of Public Health. 2011;35(2):146-50.62. Hanna B, Rolls C. How do early parenting centres support women with an infant who has a sleep problem? Contemporary nurse : a journal for the Australian nursing profession. 2001;11(2-3):153-62.63. Rowe HJ, Fisher JRW. The contribution of Australian residential early parenting centres to comprehensive mental health care for mothers of infants: Evidence from a prospective study. International Journal of Mental Health Systems. 2010;4.64. Petzoldt J, Witchen H, Einsle E, Martini J. Maternal anxiety versus depressive disorders: Specific relations to infants’ crying, feeding and sleeping problems. Child Care Health and Development. 2016;42:231-45.65. Field T. Infant sleep problems and interventions: A review. Infant Behavior and Development. 2017;47:40-53.66. Dahlen HG, Foster JP, Psaila K, Badawi N, Fowler C, Schmied V, et al. Gastro-oesophageal reflux: a mixed methods study of infants admitted to hospital in the first 12 months following birth in NSW (2000–2011). BMC Pediatrics. 2018;18(30):DOI 10.1186/s12887-018-0999-9.

Figure legend

Figure 1. Gestational age at birth comparison between babies admitted to residential

parenting services and those not admitted

Figure 2. Birth trauma as coded on birth admission for babies who enter residential

parenting services as compared to all other babies

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For peer review only<37

weeks37 38 39 40 41 42 >42

0

5

10

15

20

25

30

residential

non residential

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Intracranial laceration and haemorrhage

Other birth trauma to central nervous

system

Birth trauma to scalp Birth trauma to skeleton

Birth trauma to peripheral nervous

system

Other birth trauma0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

Residential

All other births

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Journal: BMJ Open

Manuscript ID bmjopen-2019-030133.R1

Article Type: Original research

Date Submitted by the Author: 09-Apr-2019


<b>Primary Subject Heading</b>: Epidemiology

Secondary Subject Heading: Nursing, Obstetrics and gynaecology, Paediatrics



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Locked Bag 1797


[email protected]





Flinders University

[email protected]




Tel: 61 2 0407942916

[email protected]



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Locked Bag 1797


Tel: 61 2 9 685 9505

[email protected]

Abstract



following birth.

Design: A linked population data cohort study was undertaken for the years 2000-2012.


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admitted to RPS.

Results: During the time period there were a total of 1 097 762 births (2000-2012) in

NSW and 32 991 admissions to RPS. Women in cohort 1: (those admitted to RPS) were

older at the time of birth, more likely to be admitted as a private patient at the time of

birth, be born in Australia and be having their first baby compared to women in cohort

2 (those not admitted to a RPS). Women admitted to RPS experienced more birth

intervention (induction, instrumental birth, caesarean section), had more multiple

births and were more likely to have a male infant. Their babies were also more likely to

be resuscitated and have experienced birth trauma (particularly to the scalp). Between

2000-2012 the average age of women in the RPS increased by nearly two years; their

infants were older on admission and women were less likely to smoke. Over the time

period there was a drop in the numbers of women admitted to RPS having a normal

vaginal birth and an increase in women having an instrumental birth.


advantaged and have higher birth intervention than those who do not, due in part to

higher numbers birthing in the private sector where intervention rates are high. The

rise in women admitted to RPS (2000-2012) who have had instrumental births is

intriguing as overall rates did not increase.



Strengths:

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NSW





Limitations:





Introduction










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identified as tertiary level services and are an escalation of the universal child and

family health services available within Australia that has been established for over 100

years. Admission to an RPS requires a referral from a universal child and family health

service, general practitioner (family doctor), midwife or allied health professional.

There is no preference given to women with private or public insurance status. Referral

is based on need. However, we know women who are more advantaged and hence more

likely to have private insurance engage more with services and seek support more

readily than those from lower socioeconomic backgrounds.

These RPS services are registered nurse-led. The nurses have additional qualifications

in child and family health nursing and increasingly many also have qualifications in

adult and/or infant mental health nursing. The nurses have a close working relationship

with onsite psychologists and social workers. Medical support is provided by visiting

paediatricians, psychiatrists, and in the last five years also by general practitioners . The

nurses are responsible for physical and psychosocial assessment of the caregiver

(primarily mothers) and her infant during admission to the residential unit, working

collaboratively with the parent to design targeted parenting interventions, and

supporting the implementation and evaluation of these interventions. When mothers

are identified as requiring additional psychosocial (including housing, financial

concerns, child protection or family violence) and mental health support or medical

intervention a referral is made to the residential psychologist, social worker or the

appropriate visiting medical specialist.

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Due to the initial focus on parenting issues (feeding, sleep and settling problem), once

the mother is admitted mental health concerns of depression, anxiety and other forms

of mental illness and psychosocial risk are regularly identified. The mother is then

referred for specialist assessment and if required treatment is commenced.

RPS are funded as not-for-profit health affiliated or government services Parents and

their infants or young children are able to access these services without out-of-pocket

costs once admitted as a public or private patient. There is close alignment to the

population-based child and family health nursing service offered to all children and

families following birth (similar to the English health visiting service) and they follow a

parent and infant centred approach to the provision of care. In NSW (Australia’s most

populous state) around 3,400 women (3.5% of the birthing population) use the RPS of

Tresillian (three RPS) and Karitane (two RPS) each year [9, 10]. Overall there are

significant similarities between the two services in NSW as there is often collaboration

in the development of clinical guidelines. In states such as Victoria around 5% of

women are admitted to RPS [11]. Referrals to these organisations come from all over

NSW [12, 13]. The demand for RPS is high with waiting lists reported between four-to-

ten weeks in most states [14]. Less is known about changes in the populations’

characteristics and reasons for seeking RPS care over time.

Aim




Methods

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Data sources























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perfectly or nearly perfectly on first name, surname, date of birth and address have a high

linkage weight, and records that match only on date of birth have a low linkage weight. If

the linkage weight is high it is likely that the records truly match, and if the linkage weight

is low it is likely that the records are not truly a match. This technique has been shown to

have a false positive rate of 0.3% of records [16].






Subjects












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Data analysis




normally distributed. Variables with missing data greater than 1.0% were excluded from

the analyses. Cells with n<5 were not included when conducting statistical comparisons.

Taking into account the size of the cohort and the number of analyses undertaken, results

were considered significant at the level p<0.01. Analysis was undertaken with IBM SPSS

v.23®

Ethics



services for release of de-identified data from each site.

Results

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were 32 071 admissions to the RPS of Tresillian and Karitane in NSW.



who were admitted to RPS to those who were not) are displayed in Table 1. Women

admitted to RPS were on average two years older, more likely to be born in Australia

and almost half as likely to smoke. Nearly three quarters (72.5%) were >5th decile for

socio-economic advantage and disadvantage and over two thirds (67.2%) were >5th

decile for education and occupation. On average women stayed 4.4 days in the RPS and

this was slightly longer in Tresillian RPS. Women admitted to RPS were more likely to

have a multiple birth and be primiparous. While the vast majority of women were

admitted for one baby, some had several admissions for the same child and some

women had admissions for subsequent children during the time period (2000-2012)

(Table 1).

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NSW

All women n=355 100


Both facilities

All women n=32 991

All babies n=33 035

Karitane

n= 6651 (mothers)

n= 6663 (babies)

Tresillian

n=26 340 (mothers)

n=26 372 (babies)

Age

Mother

Baby

Mean 30.4 (SD 5.60)

Range 12-54

Mean 32.2 (SD 5.36)

Range 12 – 54

Median 228 days


Mean 31.6 (SD 5.25)

Range 13-51

Median 243 days


Mean 32.4 (SD 5.37)

Range 12-54

Median 227 days


Smoking 13.9% 7.4% 7.2% 7.4%

Australian born 70.6% 78.1% 73.8% 79.2%

SEIFA (>5th decile for index of socio-economic advantage & disadvantage

55.4% 72.5% 58.8% 75.7%

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51.8% 67.2% 57.9% 69.4%


Range 0-29

Mean 4.1 (SD 1.47)

Range 1-16

Mean 4.4 (SD 1.32)

Range 0-29

Discharge type

Standard

Own risk

99.8%

0.2%

99.3%

0.7%

99.9%

0.1%

Plurality

Singletons

Twins

Triplets

Quads

1 080 541 (98.5%)

16 892 (1.5%)

317 (0.03%)

12 (0.001%)

31 294 (94.7%)

1698 (5.1%)

40 (0.13%)

3 (0.0095)

6359 (95.4%)

298 (4.5%)

6 (0.09%)

0 (0.0%)

24 935 (94.6%)

1400 (5.3%)

34 (0.13%)

3 (0.01%)

Parity

Primiparous

Multiparous

42.2%

57.8%

62.8%

37.2%

61.1%

38.9%

63.2%

36.8%


1- 23 595

2 - 9076

1 - 4426

2 - 2141

1 – 19 169

2 - 6935

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3 - 331

4 - 32

5 - 1

3 - 84

4 – 12

5 - 0

3 - 247

4 - 20

5 - 1


1 – 32 991

2 - 18

1 – 6651

2 - 6

1 – 26 340

2 - 16

Health Insurance status

Public – Medicare only

Private health insurance – utilised onhospital admission

Other (overseas visitor for e.g.)

17 214 (52.1%)

15 799 (47.8%)

22 (0.1%)

3305 (49.6%)

3357 (50.1%)

1 (0.3%)

12 494 (47.4%)

13 857 (52.5%)

21 (0.1%)

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induction of labour, epidural or episiotomy compared to women not admitted to RPS

(Table 2). There were no major differences in the incidence of hypertensive disease of

pregnancy and diabetes in women who were admitted to RPS. More women who were

admitted to the RPS had male babies. Babies were more likely to have been born at 37

and 38 weeks gestation and less likely to be born over 40 weeks compared to babies

who did not get admitted to a RPS (Fig 1). Neonatal outcomes at birth tended to be

worse for babies of women admitted to RPS, with more SCN/NICU admissions and

resuscitation at birth. Birth trauma was also examined (Figure 2) and women admitted

to RPS were more likely to have given birth to a neonate who suffered scalp trauma.

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NSW

All women n=355 100


Both facilities

All women n=32 991

All babies n=33 035

Karitane

n=6651 (mothers)

n=6663 (babies)

Tresillian

n=26 340 (mothers)

n=26 372 (babies)

Place of birth

Hospital

Birth centre

Home Birth

Born before arrival

96.8%

2.5%

0.2%

0.5%

96.9%

2.8%

0.1%

0.2%

96.9%

2.7%

0.1%

0.1%

96.9%

2.8%

0.1%

0.2%

Place of birth

Public hospital

Private Hospital


59.2%

36.1%

4.6%

49.5%

50.5%

0.0%

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Type of delivery

Vaginal

Forceps

Vacuum extraction

Vaginal breech

Caesarean section

Elective

Emergency

60.5%

3.6%

7.0%

0.6%

28.3%

16.3%

12.0%

48.9%

5.3%

9.9%

0.8%

34.8%

18.9%

15.9%

51.8%

5.7%

9.8%

0.5%

32.3%

18.1%

14.3%

48.2%

5.2%

9.9%

0.9%

35.5%

19.1%

16.3%

Episiotomy 11.6% 15.0% 15.8% 15.0%

Labour induced 25.1% 27.8% 27.2% 28.0%

Pain relief

None

Epidural

15.1%

25.4%

9.4%

38.4%

8.9%

36.4%

9.5%

39.0%


6.8% 8.3% 7.2% 8.6%

Diabetes 5.3% 4.9% 5.6% 4.7%

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Baby sex male 51.4% 55.4% 54.6% 55.6%

Gestation at delivery 38.9 (2.20)* 38.8 (2.10)* 38.8 (2.10)* 38.7 (2.10)*

Birthweight 3369.5 (602.80)* 3309.4 (615.79)* 3310.9 (617.75)* 3303.1 (607.99)*

Apgar <7 2.1% 1.4% 1.6% 1.4%

Admitted SCN/NICU 15.6% 20.1% 19.5% 20.3%


38.5% 43.8% 41.5% 44.4%

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residential parenting services and those not admitted









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Description



Feeding P92.2/P92.3/P92.4/

P92.5/P92.8/P93.9/R63.3



Appearance

/behaviour




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Sleeping F51.2/G47.2/G47.9/ G47.0/ G47.8/ G47.1


Feeding R63.3/ F98.2/ P92.5/ P92.8/P92.9






Social/other Z76.2/Z76.8 <1% persons encountering health services in unspecified circumstances /health supervision and care of others healthy infant and child -

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adverse socioeconomic circumstances, awaiting foster or adoptive placement

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F32.21/ F41.2/ F41.1/ F32.20/ F32.9/ F32.90/ F41.9/ F32.91/ F34.1/ F32.2/ F43.0/ F32.11


Feeding Z39.1/ O92.50/ O92.41/ O92.11/ O92.71/ O92.10





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The trends over time divided into three epochs were examined regarding the characteristics of women admitted to RPS. Women

admitted to RPS were significantly older towards the end of the third time period when compared to the first when they gave birth and

their babies were older at admission between the two epochs. The rate of women who were smoking had more than halved over the

same time period. We also found that women admitted were much less likely to have had a normal vaginal birth and much more likely to

have an instrumental birth in the last time period compared to the first. Babies admitted to RPS were also less likely to have been

admitted to SCN/NICU (Table 7). The target group for admission to the NSW RPS has remained consistent during the 12 year period

examined.

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93.8%5.2%

94.7%5.3%

94.9%5.1%

0.45


63.2%36.8%

63.0%37.0%

63.0%37.0%

0.76


96.9%2.8%0.1%0.2%

96.8%2.7%0.1%0.4%

96.9%2.8%0.1%0.2%


33.4%66.4%

35.1%64.9%

34.8%65.2%

0.54


52.5%17.2%30.3%

45.1%18.4%36.4%

41.6%23.3%35.0%

<0.001

Gestation (weeks)* 38.5 38.5 38.6 1.00Admitted to SCN/NICU 26.6% 24.5% 20.9% <0.001

*calculated from last menstrual cycle or earliest ultrasound undertaken **cell count<5 statistics unable to be calculated


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Discussion






RPS.









triplets. We also found the SEIFA index was higher amongst women admitted which








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(PTSD) [25] .







of knowledge and misinformation about services [26] . While some families willingly

seek out an admission to an RPS due to the lack of stigma attached; “hard to reach”

families have been identified as having minimal informal and formal supports systems

that limit their ability to successfully connect with services that can provide parenting

support [27]. Previous experiences of insensitive professional approaches can leave

parents with a sense of being judged and placed under surveillance [27].

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Birth intervention






















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physically and psychologically, as well as babies [21, 44]. Starting life as a baby with

birth trauma and trying to mother with physical and psychological trauma is not ideal

and may explain the apparent trend in more women going to RPS who have had

caesareans and instrumental birth. However, while caesarean section has increased

during this time period there was minimal change in the incidence of instrumental birth

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in NSW (10.7% in 2000 and 11.3% in 2012), so it is interesting to see this change in

those who are seeking RPS. It could be possible practitioners are now less skilful with

instruments, such as forceps, due to the increased use of vacuum delivery and this may

be leading to increased maternal damage. More research is needed to unpick this

intriguing observation. Other studies we have undertaken have shown the high rate of

severe perineal trauma with instrumental birth [20]. In another study we undertook

looking at the medical records of women seeking RPS, we found caesarean section and

forceps were both identified as contributing to birth trauma [45].













In NSW as whole there were significant changes in demographics and obstetric

interventions which clearly are also impacting on some of the changes we saw over time

in the RPS admission characteristics. Smoking declined NSW wide from 17.3% in 2000

to 10.4% in 2012. Maternal age increased from 29.28 to 30.31 years in the time period.

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Women giving birth who were themselves born in Australia declined from 72.2% to

65.1%. Instrumental birth remained relative stable between 2000 and 2012 (10.7% to

11.3%). Vaginal birth declined from 67.4% to 57% and the caesarean section rate

changed from 21.8% to 31.8% over the time period. The majority of the change to the

spontaneous vaginal birth rate came from an increase of 10 percentage points in the

caesarean section rate over 12 years.


















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Limitations














association that is not directly linked and further research is needed to confirm this. We

could not include fathers in the analysis and this is another acknowledged limitation of

this study.

Conclusion




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Contributors:


Funding




NSW from 2000-2012


We do not have ethics approval to share data. We do not have permission to give the data to anyone else except those listed in the ethics. Data may be obtained from NSW Health and linked by the NSW Centre for Health Record Linkage (CHeReL) following appropriate ethics approval

PPI statement

A waiver of consent was obtained for the undertaking of this research with

consideration of the fact of the difficulty in obtaining consent considering the

retrospective nature of the study and the fact that only de-identified information was

recorded from the medical records reviewed

Competing interests: ICMJE uniform disclosure form has been completed.




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Acknowledgments




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59. Hanna B, Rolls C. How do early parenting centres support women with an infant who has a sleep problem? Contemporary nurse : a journal for the Australian nursing profession. 2001;11(2-3):153-62.60. Rowe HJ, Fisher JRW. The contribution of Australian residential early parenting centres to comprehensive mental health care for mothers of infants: Evidence from a prospective study. International Journal of Mental Health Systems. 2010;4.61. Petzoldt J, Witchen H, Einsle E, Martini J. Maternal anxiety versus depressive disorders: Specific relations to infants’ crying, feeding and sleeping problems. Child Care Health and Development. 2016;42:231-45.62. Field T. Infant sleep problems and interventions: A review. Infant Behavior and Development. 2017;47:40-53.63. Dahlen HG, Foster JP, Psaila K, Badawi N, Fowler C, Schmied V, et al. Gastro-oesophageal reflux: a mixed methods study of infants admitted to hospital in the first 12 months following birth in NSW (2000–2011). BMC Pediatrics. 2018;18(30):DOI 10.1186/s12887-018-0999-9.

Figure legend





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Figure 1. Gestational age at birth comparison between babies admitted to residential parenting services and those not admitted

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Figure 2. Birth trauma as coded on birth admission for babies who enter residential parenting services as compared to all other babies

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Journal: BMJ Open



Date Submitted by the Author: 24-Jun-2019






BMJ Open on A


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Locked Bag 1797


[email protected]





Flinders University

[email protected]




Tel: 61 2 0407942916

[email protected]



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Locked Bag 1797


Tel: 61 2 9 685 9505

[email protected]

Abstract



following birth.



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admitted to RPS.





2 (those not admitted to a RPS) (p<0.01). Women admitted to RPS experienced more

birth intervention (induction, instrumental birth, caesarean section), had more multiple

births and were more likely to have a male infant (p<0.01). Their babies were also more

likely to be resuscitated and have experienced birth trauma to the scalp (p<0.01).

Between 2000-2012 the average age of women in the RPS increased by nearly two

years; their infants were older on admission and women were less likely to smoke. Over

the time period there was a drop in the numbers of women admitted to RPS having a

normal vaginal birth and an increase in women having an instrumental birth.








Strengths:

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NSW





Limitations:





Introduction










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Aim




Methods

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Data sources























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Subjects












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Data analysis




normally distributed. Variables with missing data greater than 1.0% were excluded from

the analyses. Cells with n<5 were not included when conducting statistical comparisons.

Taking into account the size of the cohort and the number of analyses undertaken, results

were considered significant at the level p<0.01. Analysis was undertaken with IBM SPSS

v.23®

Ethics



services for release of de-identified data from each site. A waiver of consent was

obtained for the undertaking of this research with consideration of the fact of the

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difficulty in obtaining consent considering the retrospective nature of the study and the

fact that only de-identified information was recorded from the medical records

reviewed

Patient and public involvement

There was no patient involvement in this study as it used de-identified data that had

already been gathered.

Results


were 32 991 women admitted to the RPS of Tresillian and Karitane in NSW.



who were admitted to RPS to those who were not) are displayed in Table 1. When

compared to women who were not admitted to RPS, women admitted to RPS were on

average two years older (p,0.01), more likely to be born in Australia (p<0.01) and

almost half as likely to smoke (p<0.01). Nearly three quarters (72.5%) were >5th decile

for socio-economic advantage and disadvantage(p<0.01) and over two thirds (67.2%)

were >5th decile for education and occupation(p<0.01) . On average women stayed 4.4

days in the RPS. Women admitted to RPS, when compared to women who were not

admitted to RPS, were more likely to have a multiple birth(p<0.01) and be

primiparous(p<0.01) . While the vast majority of women were admitted for one baby,

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some had several admissions for the same child and some women had admissions for

subsequent children during the time period (2000-2012) (Table 1).

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NSW (not admitted)

All women n=322 109


Admitted both facilities

All women n=32 991

All babies n=33 035

p Karitane

n= 6651 (mothers)

n= 6663 (babies)

Tresillian

n=26 340 (mothers)

n=26 372 (babies)

Age

Mother

Baby

Mean 30.4 (SD 5.60)

Range 12-54

Mean 32.2 (SD 5.36)

Range 12 – 54

Median 228 days


<0.01 Mean 31.6 (SD 5.25)

Range 13-51

Median 243 days


Mean 32.4 (SD 5.37)

Range 12-54

Median 227 days


Smoking 13.9% 7.4% <0.01 7.2% 7.4%

Australian born 70.6% 78.1% <0.01 73.8% 79.2%

SEIFA (>5th decile for index of socio-economic advantage &

55.4% 72.5% <0.01 58.8% 75.7%

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disadvantage


51.8% 67.2% <0.01 57.9% 69.4%

Length of stay in RPS

Mean 4.4 (SD 1.35)

Range 0-29

Mean 4.1 (SD 1.47)

Range 1-16

Mean 4.4 (SD 1.32)

Range 0-29

Discharge type

Standard

Own risk

99.8%

0.2%

99.3%

0.7%

99.9%

0.1%

Plurality

Singletons

Twins

Triplets

Quads

1 080 541 (98.5%)

16 892 (1.5%)

317 (0.0%)

12 (0.0%)

31 294 (94.7%)

1698 (5.1%)

40 (0.1%)

3 (0.0%)

<0.01 6359 (95.4%)

298 (4.5%)

6 (0.1%)

0 (0.0%)

24 935 (94.6%)

1400 (5.3%)

34 (0.1%)

3 (0.0%)

Parity

Primiparous 42.2% 62.8% <0.01 61.1% 63.2%

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Multiparous 57.8% 37.2% 38.9% 36.8%


1- 23 595

2 - 9076

3 - 331

4 - 32

5 - 1

1 - 4426

2 - 2141

3 - 84

4 – 12

5 - 0

1 – 19 169

2 - 6935

3 - 247

4 - 20

5 - 1


1 – 32 991

2 - 16

1 – 6651

2 - 6

1 – 26 340

2 - 16

Health Insurance status for birth


Private health insurance – utilised on hospital admission


768 733 (72.2%)

235 305 (22.1%)

60 689 (5.7%)

17 214 (52.1%)

15 799 (47.8%)

22 (0.1%)

P<0.01 3357 (50.4%)

3305 (49.6%)

1 (0.0%)

13 857 (52.5%)

12 494 (47.4%)

21 (0.1%)

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the rest of the NSW population (p0.32). Substantially fewer women who were admitted

to RPS had a normal vaginal birth and more had an instrumental birth or caesarean

section, induction of labour, epidural or episiotomy compared to women not admitted

to RPS (p<0.01) (Table 2). There were significant differences in the incidence of

hypertensive disease of pregnancy and diabetes in women who were admitted to RPS

(p<0.01) . More women who were admitted to the RPS had male babies (p<0.01). Babies

were more likely to have been born at 37 and 38 weeks gestation and less likely to be

born over 40 weeks compared to babies who did not get admitted to a RPS (p<0.01)

(Fig 1). Neonatal outcomes at birth tended to be worse for babies of women admitted to

RPS, with more SCN/NICU admissions(p<0.01) and resuscitation at birth(p<0.01) .

Birth trauma was also examined (Figure 2) and women admitted to RPS were more

likely to have given birth to a neonate who suffered scalp trauma(p<0.01) .

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NSW (not admitted)

All women n=322 109



All women n=32 991

All babies n=33 035

p Karitane

n=6651 (mothers)

n=6663 (babies)

Tresillian

n=26 340 (mothers)

n=26 372 (babies)

Place of birth

Hospital

Birth centre

Home Birth

Born before arrival

96.8%

2.5%

0.2%

0.5%

96.9%

2.8%

0.1%

0.2%

0.32 96.9%

2.7%

0.1%

0.1%

96.9%

2.8%

0.1%

0.2%

Place of birth

Public hospital

Private Hospital


59.2%

36.1%

4.6%

49.5%

50.5%

0.0%

p<0.01

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Type of delivery

Vaginal

Forceps

Vacuum extraction

Vaginal breech

Caesarean section

Elective

Emergency

60.5%

3.6%

7.0%

0.6%

28.3%

16.3%

12.0%

48.9%

5.3%

9.9%

0.8%

34.8%

18.9%

15.9%

p<0.01 51.8%

5.7%

9.8%

0.5%

32.3%

18.1%

14.3%

48.2%

5.2%

9.9%

0.9%

35.5%

19.1%

16.3%

Episiotomy 11.6% 15.0% p<0.01 15.8% 15.0%

Labour induced 25.1% 27.8% p<0.01 27.2% 28.0%

Pain relief

None

Epidural

15.1%

25.4%

9.4%

38.4%

p<0.01 8.9%

36.4%

9.5%

39.0%


6.8% 8.3% p<0.01 7.2% 8.6%

Diabetes 5.3% 4.9% p<0.01 5.6% 4.7%

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Baby sex male 51.4% 55.4% p<0.01 54.6% 55.6%

Gestation at delivery

38.9 (2.20)* 38.8 (2.10)* P=0.71 38.8 (2.10)* 38.7 (2.10)*

Birthweight 3369.5 (602.80)* 3309.4 (615.79)* p<0.01 3310.9 (617.75)* 3303.1 (607.99)*

Apgar <7 2.1% 1.4% p<0.01 1.6% 1.4%

Admitted SCN/NICU

15.6% 20.1% p<0.01 19.5% 20.3%


38.5% 43.8% p<0.01 41.5% 44.4%

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residential parenting services and those not admitted – all gestation comparisons

p<0.01









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Description



Feeding P92.2/P92.3/P92.4/

P92.5/P92.8/P93.9/R63.3



Appearance

/behaviour




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Sleeping F51.2/G47.2/G47.9/ G47.0/ G47.8/ G47.1


Feeding R63.3/ F98.2/ P92.5/ P92.8/P92.9







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F32.21/ F41.2/ F41.1/ F32.20/ F32.9/ F32.90/ F41.9/ F32.91/ F34.1/ F32.2/ F43.0/ F32.11


Feeding Z39.1/ O92.50/ O92.41/ O92.11/ O92.71/ O92.10





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older in the third time period when compared to the first when they gave birth and their

babies were older at admission between the two epochs(p<0.01) . The rate of women

who were smoking had more than halved over the same time period. We also found that

women admitted were much less likely to have had a normal vaginal birth and much

more likely to have an instrumental birth in the last time period compared to the first

(p<0.01). Babies admitted to RPS were also less likely to have been admitted to

SCN/NICU (p<0.01) (Table 7). The target group for admission to the NSW RPS has

remained consistent during the 12 year period examined.

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93.8%5.2%

94.7%5.3%

94.9%5.1%

0.45


63.2%36.8%

63.0%37.0%

63.0%37.0%

0.76


96.9%2.8%0.1%0.2%

96.8%2.7%0.1%0.4%

96.9%2.8%0.1%0.2%


33.4%66.4%

35.1%64.9%

34.8%65.2%

0.54


52.5%17.2%30.3%

45.1%18.4%36.4%

41.6%23.3%35.0%

<0.01

Gestation (weeks)* 38.5 38.5 38.6 1.00Admitted to SCN/NICU 26.6% 24.5% 20.9% <0.01


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*calculated from last menstrual cycle or earliest ultrasound undertaken **cell count<5 statistics unable to be calculated

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Discussion






RPS.

















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(PTSD) [25] .













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Birth intervention






















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Limitations
















this study.

Conclusion




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Contributors:


Funding




NSW from 2000-2012







Acknowledgments




References

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43. O'Mahony F, Hofmeyr GJ, Menon V. Choice of instruments for assisted vaginal delivery Cochrane Database of Systematic Reviews. 2010;DOI: 10.1002/14651858.CD005455.pub2.44. Muraca G.M, Skioll A, Lisonkova S, Sabr Y, Brant R, Cundiff GW, et al. Perinatal and maternal morbidity and mortality among term singletons following midcavity operative vaginal delivery versus caesarean delivery. BJOG. 2017;10.1111/1471-0528.14820.45. Priddis H, Thornton C, Fowler C, Schmied V, Tooher J, Dickenson M, et al. Characteristics and service needs of women and babies admitted to residential parenting units in New South Wales: A mixed-methods study. Journal of Clinical Nursing 2018;|https://doi.org/10.1111/jocn.14497.46. Smith L. Impact of birthing practices on the breastfeeding dyad. Journal of Midwifery & Women's Health 2010;52(6):621-30.47. Fernández IO, MM< G, Martínez AM, Morillo A F-C, Sánchez FL, Costarelli V. Newborn feeding behaviour depressed by intrapartum oxytocin: a pilot study. Acta Paediatrica. 2012;101(7):749-54.48. Carter CS. Developmental consequences of oxytocin. Physiol Behav. 2003;(79):383-97.49. Hyde MJ, Mostyn A, Modi N, Kemp PR. The health implications of birth by caesarean section. Biological Reviews. 2012;87(1):229-43.50. McLaughlin FJ, O’Connor S, Deni R. Infant state and behavior during the first postpartum hour. The Psychological Record 1981;31:455–8.51. Widstrom A-M, Ransjo-Arvidson AB, Christensson K, Matthiesen A- S, Winberg J, Uvnas-Moberg K. Gastric suction in healthy newborn infants. Effects on circulation and developing feeding behaviour. Acta Paediatr. 1987;76:566–72.52. Righard L. How do newborns find their mother’s breast? . Birth. 1995;22:174–5.53. Fisher J, Astbury J, Smith A. Adverse psychological impact of operative obstetric interventions: a prospective study. Aust NZ J Psychiatry 1997;31:728–38.54. Prior E, Santhakumaran S, Gale C, Philipps LH, Modi N, Hyde MJ. Breastfeeding after ceasrean delivery: a systematic review and meta-analysis of world literature. American Journal of Clinical Nutrition 2012;Online ISSN: 1938-3207.55. Brown S, Lumley J. Maternal health after childbirth: results of an Australian population survey. British Journal of Obstetrics and Gynaecology. 1998;105:156-61.56. Thompson JF, Roberts CL, Currie M, Ellwood DA. Prevalence and Persistence of Health Problems After Childbirth: Associations with Parity and Method of Birth. Birth. 2002;29(2):83-94.57. Saurel-Cubizolles MJ, Romito P, Lelong N, Ancel PY. Women's health after childbirth: a longitudinal study in France and Italy. BJOG. 2000;107(10):1202-9.58. Fisher JRW, Rowe HJ, Hammarberg K. Admission of women, with their infants, for psychological and psychiatric causes in Victoria, Australia. Australian and New Zealand Journal of Public Health. 2011;35(2):146-50.59. Hanna B, Rolls C. How do early parenting centres support women with an infant who has a sleep problem? Contemporary nurse : a journal for the Australian nursing profession. 2001;11(2-3):153-62.60. Rowe HJ, Fisher JRW. The contribution of Australian residential early parenting centres to comprehensive mental health care for mothers of infants: Evidence from a prospective study. International Journal of Mental Health Systems. 2010;4.61. Petzoldt J, Witchen H, Einsle E, Martini J. Maternal anxiety versus depressive disorders: Specific relations to infants’ crying, feeding and sleeping problems. Child Care Health and Development. 2016;42:231-45.62. Field T. Infant sleep problems and interventions: A review. Infant Behavior and Development. 2017;47:40-53.63. Dahlen HG, Foster JP, Psaila K, Badawi N, Fowler C, Schmied V, et al. Gastro-oesophageal reflux: a mixed methods study of infants admitted to hospital in the first 12 months following birth in NSW (2000–2011). BMC Pediatrics. 2018;18(30):DOI 10.1186/s12887-018-0999-9.

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Figure legend





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Figure 1. Gestational age at birth comparison between babies admitted to residential parenting services and those not admitted – all gestation comparisons p<0.01

51x31mm (300 x 300 DPI)

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65x38mm (300 x 300 DPI)

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Journal: BMJ Open



Date Submitted by the Author: 16-Aug-2019






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Locked Bag 1797


[email protected]





Flinders University

[email protected]




Tel: 61 2 0407942916

[email protected]



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Grainne O’Loughlin BSc. (Hons) Speech Therapy, MBA CEO










Locked Bag 1797


Tel: 61 2 9 685 9505

[email protected]

Abstract



following birth.



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admitted to RPS.





2 (those not admitted to a RPS). Women admitted to RPS experienced more birth

intervention (induction, instrumental birth, caesarean section), had more multiple

births and were more likely to have a male infant. Their babies were also more likely to

be resuscitated and have experienced birth trauma to the scalp. Between 2000-2012 the

average age of women in the RPS increased by nearly two years; their infants were

older on admission and women were less likely to smoke. Over the time period there

was a drop in the numbers of women admitted to RPS having a normal vaginal birth and

an increase in women having an instrumental birth.








Strengths:

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NSW





Limitations:





Introduction










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Aim




Methods

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Data sources























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Subjects

















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Data analysis




normally distributed reported as means and standard deviations or with Mann-Whitney

U for non-parametric results, reported as medians and interquartile range. Variables with

missing data greater than 1.0% were excluded from the analyses. Cells with n<5 were not

included when conducting statistical comparisons. Proportional results with more than

two categories were examined utilising the chi-squared statistic for all groups as reported

in in tables and figure 1. Taking into account the size of the cohort and the number of

analyses undertaken, results were considered significant at the level p<0.01. Results

were reported to three decimal points for all those >0.001 and all results less than 0.001

were reported as <0.001. Analysis was undertaken with IBM SPSS v.23®

Ethics



services for release of de-identified data from each site. A waiver of consent was

obtained for the undertaking of this research with consideration of the fact of the

difficulty in obtaining consent considering the retrospective nature of the study and the

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fact that only de-identified information was recorded from the medical records

reviewed

Patient and public involvement

There was no patient involvement in this study as it used de-identified data that had

already been gathered.

Results


were 32 991 women admitted to the RPS of Tresillian and Karitane in NSW.



who were admitted to RPS to those who were not) are displayed in Table 1. When

compared to women who were not admitted to RPS, women admitted to RPS were on

average two years older, more likely to be born in Australia and almost half as likely to

smoke. Nearly three quarters (72.5%) were >5th decile for socio-economic advantage

and disadvantage and over two thirds (67.2%) were >5th decile for education and

occupation. On average women stayed 4.4 days in the RPS. Women admitted to RPS,

when compared to women who were not admitted to RPS, were more likely to have a

multiple birth and be primiparous. While the vast majority of women were admitted for

one baby, some had several admissions for the same child and some women had

admissions for subsequent children during the time period (2000-2012) (Table 1).

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NSW (not admitted)

n=1 064 727 (births)


n=33 035 (births)

pvalue Karitane

n= 6663 (births)

Tresillian

n=26 372 (births)

Age

Mother (at time of birth in years*)

Baby (at time of admission in days†)

30.4 (5.60)

Range 12-54

32.2 (5.36)

Range 12 – 54

228 (12-336)


<0.001 31.6 (5.25)

Range 13-51

243 (11-334)


32.4 (5.37)

Range 12-54

227 (9-325)


Smoking 13.9% 7.4% <0.001 7.2% 7.4%

Australian born 70.6% 78.1% <0.001 73.8% 79.2%

SEIFA (>5th decile for index of socio-economic advantage

55.4% 72.5% <0.001 58.8% 75.7%

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& disadvantage


51.8% 67.2% <0.001 57.9% 69.4%


Range 0-29

Mean 4.1 (SD 1.47)

Range 1-16

Mean 4.4 (SD 1.32)

Range 0-29

Discharge type

Standard

Own risk

99.8%

0.2%

99.3%

0.7%

99.9%

0.1%

Plurality‡

Singletons

Twins

Triplets

Quads

1 080 541 (98.5%)

16 892 (1.5%)

317 (0.0%)

12 (0.0%)

31 294 (94.7%)

1698 (5.1%)

40 (0.1%)

3 (0.0%)

<0.001 6359 (95.4%)

298 (4.5%)

6 (0.1%)

0 (0.0%)

24 935 (94.6%)

1400 (5.3%)

34 (0.1%)

3 (0.0%)

Parity‡

Primiparous

Multiparous

42.2%

57.8%

62.8%

37.2%

<0.001 61.1%

38.9%

63.2%

36.8%

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All analyses conducted on data at time of birth (for both mother and baby) unless indicated otherwise


1- 23 595

2 - 9076

3 - 331

4 - 32

5 - 1

1 - 4426

2 - 2141

3 - 84

4 – 12

5 - 0

1 – 19 169

2 - 6935

3 - 247

4 - 20

5 - 1


1 – 32 991

2 - 16

1 – 6651

2 - 6

1 – 26 340

2 - 16

Health Insurance status for birth‡


Private health insurance – utilised on hospital admission


768 733 (72.2%)

235 305 (22.1%)

60 689 (5.7%)

17 214 (52.1%)

15 799 (47.8%)

22 (0.1%)

P<0.001 3357 (50.4%)

3305 (49.6%)

1 (0.0%)

13 857 (52.5%)

12 494 (47.4%)

21 (0.1%)

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*mean and standard deviation, † median and interquartile range, ‡chi-squared analysis undertaken across all groups

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induction of labour, epidural or episiotomy compared to women not admitted to RPS

(Table 2). There were significant differences in the incidence of hypertensive disease of

pregnancy and diabetes in women who were admitted to RPS. More women who were

admitted to the RPS had male babies. Babies were more likely to have been born at 37

and 38 weeks gestation and less likely to be born over 40 weeks compared to babies

who did not get admitted to a RPS (Fig 1). Neonatal outcomes at birth tended to be

worse for babies of women admitted to RPS, with more SCN/NICU admissions and

resuscitation at birth. Birth trauma was also examined (Figure 2) and women admitted

to RPS were more likely to have given birth to a neonate who suffered scalp trauma.

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NSW (not admitted)

n=1 064 727 (births to 322 109 women)


n=33 035 (births to 32 991 women

pvalue Karitane

n= 6663 (births to 6651 women)

Tresillian

n=26 372 (births to 26 340 women)

Place of birth*

Hospital

Birth centre

Home Birth

Born before arrival

96.8%

2.5%

0.2%

0.5%

96.9%

2.8%

0.1%

0.2%

0.323 96.9%

2.7%

0.1%

0.1%

96.9%

2.8%

0.1%

0.2%

Place of birth*

Public hospital

Private Hospital


59.2%

36.1%

4.6%

49.5%

50.5%

0.0%

<0.001

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Type of delivery*

Vaginal

Forceps

Vacuum extraction

Vaginal breech

Caesarean section

Elective

Emergency

60.5%

3.6%

7.0%

0.6%

28.3%

16.3%

12.0%

48.9%

5.3%

9.9%

0.8%

34.8%

18.9%

15.9%

<0.001 51.8%

5.7%

9.8%

0.5%

32.3%

18.1%

14.3%

48.2%

5.2%

9.9%

0.9%

35.5%

19.1%

16.3%

Episiotomy 11.6% 15.0% <0.001 15.8% 15.0%

Labour induced 25.1% 27.8% <0.001 27.2% 28.0%

Pain relief

None

Epidural

15.1%

25.4%

9.4%

38.4%

<0.001 8.9%

36.4%

9.5%

39.0%


6.8% 8.3% <0.001 7.2% 8.6%

Diabetes 5.3% 4.9% <0.001 5.6% 4.7%

Baby sex male 51.4% 55.4% <0.001 54.6% 55.6%

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*chi-squared analysis undertaken across all groups, †means and standard deviations

Gestation at delivery (in weeks†)

38.9 (2.20) 38.8 (2.10) 0.714 38.8 (2.10) 38.7 (2.10)

Birthweight (in grams)†

3369.5 (602.80) 3309.4 (615.79) <0.001 3310.9 (617.75) 3303.1 (607.99)

Apgar <7 2.1% 1.4% <0.001 1.6% 1.4%

Admitted SCN/NICU 15.6% 20.1% <0.001 19.5% 20.3%


38.5% 43.8% <0.001 41.5% 44.4%

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residential parenting services and those not admitted – all gestation comparisons

p<0.01









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Description



Feeding P92.2/P92.3/P92.4/

P92.5/P92.8/P93.9/R63.3



Appearance

/behaviour




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Sleeping F51.2/G47.2/G47.9/ G47.0/ G47.8/ G47.1


Feeding R63.3/ F98.2/ P92.5/ P92.8/P92.9







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F32.21/ F41.2/ F41.1/ F32.20/ F32.9/ F32.90/ F41.9/ F32.91/ F34.1/ F32.2/ F43.0/ F32.11


Feeding Z39.1/ O92.50/ O92.41/ O92.11/ O92.71/ O92.10





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older in the third time period when compared to the first when they gave birth and their

babies were older at admission between the two epochs. The rate of women who were

smoking had more than halved over the same time period. We also found that women

admitted were much less likely to have had a normal vaginal birth and much more likely

to have an instrumental birth in the last time period compared to the first. Babies

admitted to RPS were also less likely to have been admitted to SCN/NICU (Table 7). The

target group for admission to the NSW RPS has remained consistent during the 12 year

period examined.

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2000-2003 2004-2008 2009-2012 pvalue (epoch 1 compared to epoch 3)Maternal age (in years*) 30.3 (5.66) 30.9 (5.85) 32.0 (6.13) <0.001Infant age (in days†) 97 (0-224) 140 (13-267) 167 (40-294) <0.001Smoking 13.6% 8.5% 5.4% <0.001Australian born 76.9% 78.7% 75.6% <0.001Hypertension 10.6% 10.4% 11.7% 0.541Diabetes 4.9% 5.7% 5.0% 0.454PluralitySingletonsMultiples

93.8%5.2%

94.7%5.3%

94.9%5.1%

0.451


63.2%36.8%

63.0%37.0%

63.0%37.0%

0.762

Place of birth‡HospitalBirth centreHome BirthBorn before arrival

96.9%2.8%0.1%0.2%

96.8%2.7%0.1%0.4%

96.9%2.8%0.1%0.2%


33.4%66.4%

35.1%64.9%

34.8%65.2%

0.544


52.5%17.2%30.3%

45.1%18.4%36.4%

41.6%23.3%35.0%

<0.001

Gestation (in weeks§) 38.5 38.5 38.6 1.00Admitted to SCN/NICU 26.6% 24.5% 20.9% <0.001


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*mean and standard deviation, †median and interquartile range, ‡ cell count<5 statistics unable to be calculated, §calculated from last menstrual

cycle or earliest ultrasound undertaken

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Discussion






RPS.

















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(PTSD) [25] .













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Birth intervention








pregnancy (also associated with older maternal age)[18]. Although there was a

statistically significant difference in the incidence of diabetes and hypertension between

the two groups due to the large sample size, this was clinically quite a small difference.

These differences in intervention rates have been shown to be associated with women

who are socially advantaged and have private obstetric care in Australia [28], with

evidence of more morbidity for babies as a result, especially scalp trauma [21], which

again was demonstrated in this study.





more stress related to care of their infants compared with mothers of normal weight

infants [29, 31, 32] and highly stressed parents of preterm infants are less sensitive and

more controlling than mothers of full-term infants in dyadic play, with possible long

lasting effects on mother-child interactional behaviour [33]. Studies also indicate that

parents of small for gestational age (SGA) infants report their infant as being more

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fearful and negatively reactive compared to infants born appropriate for gestational age

[34] and that mothers have difficulty in reciprocal play with an infant born SGA and

their capacity to play with their infant moderates the relationship between infant

mental development at 12 months of age [35].





















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Limitations
















this study.

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Conclusion






Contributors:


Funding




NSW from 2000-2012







Acknowledgments

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Figure legend





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Figure 1. Gestational age at birth comparison between babies admitted to residential parenting services and those not admitted – all gestation comparisons p<0.01

51x31mm (300 x 300 DPI)

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65x38mm (300 x 300 DPI)

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