Antenatal models of care and the effect on breastfeeding rates after discharge

The exposure being studied is the type of antenatal care the woman has received for her pregnancy, specifically Midwifery Led Continuity of Care. This model of care is where the pregnant woman is cared for by the same Midwife or small group of Midwives during the antenatal, intrapartum and postnatal period. It is suggested that the relationship that is developed between the Midwife and pregnant woman may improve physical outcomes as well as satisfaction. Midwifery Led Continuity of Care is associated with a range of positive maternal and neonatal outcomes. Midwives who work within this model of care are registered as Midwives under AHPRA (Australian Health Practitioner Regulation Agency) and work on call rather than rostered shifts. They practice within their own small teams of 4 Midwives, with each Midwife being allocated 4 pregnant women each month to care for. Within each Midwifery Led Continuity of Care team there is usually 1 experienced Midwife who acts as the team leader, 2 Midwives with over 5 years’ experience in all maternity areas (antenatal, intrapartum and postnatal), and 1 Graduate Midwife who is in her first year of practising as a Midwife. Midwifery Led Continuity of Care has its philosophical foundations in the normalcy of pregnancy and birth, as well as recognising the importance of supporting and empowering the woman in decision making. This model of antenatal care is unique due to the continuity of care and this philosophy of woman centred care, and the relationship developed between Midwife and woman goes beyond patient and clinician. This observational study will follow women who expressed an interest in Midwifery Led Continuity of Care. Due to the high demand for this model of care and limited spaces available, only some women will be accepted into this mode of antenatal care. Allocations to this model of care are by a “first come, first served” basis. Women who express an interest for this model of care and placed onto a spreadsheet in time order of when their expression of interest was received, and midwifery teams then offer places to women consecutively. This study will follow both groups: women who are accepted into Midwifery Led Continuity of Care and those who were not (and therefore experience another model of care that is not Midwifery Led Continuity of Care). This model of care is currently practised within the study site, and therefore, women can access this model of pregnancy care regardless of their involvement in this study. The exposure of Midwifery Led Continuity of Care is delivered over the pregnancy, from a “booking in” appointment at around 16 weeks gestation, through to approximately 6 weeks postpartum. These appointments are conducted in the hospital antenatal clinics, community antenatal clinics or in the woman’s home. This observational study aims to commence data collection from the time of this initial booking in appointment at 16 weeks gestations, to 4 months postpartum. This study will utilise a prospective observational study design with a cohort of pregnant women, with semi-quantitative survey instruments being used as the primary data collection tool. Throughout the pregnancy, women are seen by their same assigned Midwife based on the following routine antenatal schedule: 16 weeks (phone appointment followed by face to face appointment on same day) 20-22 weeks (phone appointment) 24 weeks (phone appointment) 28-29 weeks (phone appointment followed by face to face appointment on same day) 34 weeks (phone appointment) 36 weeks (phone appointment followed by face to face appointment on same day) 40 weeks (phone appointment followed by face to face appointment on same day) 41 weeks (phone appointment followed by face to face appointment on same day) Postnatal appointments are scheduled by midwives as clinically indicated. Although the woman will attend these appointments with her midwife, this study does not follow up these women at each appointment, only at the questionnaire timepoints listed below. These routine antenatal appointments consist of phone appointments, in which the clinician provides education related to breastfeeding, diet and exercise, and birth, as well as answering questions asked by the pregnant woman. Face to face appointments consist of a maternal and fetal wellbeing check (blood pressure, fundal height measurement, fetal heart rate), as well as reviewing and ordering any tests and investigations such a pathology or ultrasounds. Both face to face and phone call appointments are allocated half an hour for each. Postnatal follow up appointments are usually based on 1 visit during the first week postnatally, and then based on clinical need for further in person follow ups. Due to the lack of structure in postnatal follow up, this data will be collected in the course of this study. Personalised schedules of appointments may be implemented due to the clinician’s discretion, for example, additional appointments during the woman’s pregnancy due to high risk pregnancy. This study will utilise questionnaires and interviews with pregnant women, and follows them until 4 months postpartum. 5 questionnaires will be sent to participants at time points: S1 – Second Trimester Antenatal Questionnaire - Sent to participants via email when they have expressed an interest in Midwifery Led Continuity of Care for their pregnancy care S2 – Third Trimester Antenatal Questionnaire - Sent to participants via email after their 36 week appointment S3 – One Week Postpartum Questionnaire - Sent to participants via email one week after they have delivered their baby S4 – One Month Postpartum Questionnaire - Sent to participants via email one month after they have delivered their baby S5 – Four Months Postpartum Questionnaire - Sent to participants via email four months after they have delivered their baby These questionnaires have been created from validated tools from pre-existing studies (Dennis, 2003; Nommsen-Rivers & Dewey, 2009; Omar, Schiffman, & Bingham, 2001; Sword et al., 2015), individual questions from previously performed questionnaires and hospital specific questions to assess key points related to RBWH models of pregnancy care. Interviews with some women will also be conducted at time points to align with the Third Trimester Antenatal Questionnaire (S2) and One Month Postpartum Questionnaire (S4). Women can indicate their interest in being part of these interviews when consenting to the study, and these interviews will be offered in a mode that suits the mother (in person, via telephone or zoom/Microsoft teams). Numbers of women to be interviewed will be guided by the concept of saturation and continued until no new or significant information is elicited through these interviews. Themes to be discussed during these interviews include: - Plans surrounding infant feeding and reasons for these intentions - Motivations to breastfeed - Familiarity of breastfeeding within the individual’s world - Relationship between antenatal caregiver and individual woman - Antenatal expectations of infant feeding and postpartum realities - Barriers to breastfeeding - Person experiences of infant feeding choices