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 was undertaken for the years 2000–2012.
Setting New South Wales (NSW), Australia.
Participants All women giving birth and babies born in NSW were compared with those 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 with women in cohort 2 (those not admitted to an 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 and 2012 the average age of women in the RPS increased by nearly 2 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.
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, 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.
- residential parenting services
- early parenting
- perinatal mental health
- caesarean section
- early term birth
- instrumental birth
- data linkage
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- residential parenting services
- early parenting
- perinatal mental health
- caesarean section
- early term birth
- instrumental birth
- data linkage
Strengths and limitations of this study
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 residential parenting services (RPS) in New South Wales.
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.
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.
Many parents experience difficulties with early parenting, in particular with breast feeding, 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 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 5 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.
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 3400 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 4 and 10 weeks in most states.14 Less is known about changes in the populations’ characteristics and reasons for seeking RPS care over time.
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.
Birth data for the time period 1 January 2000 till 31 December 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 g birth weight or 20 weeks gestation. Admission data following the birth were obtained from the NSW Admitted Patient Data Collection (APDC) until 31 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 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 socioeconomic 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 on 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
Maternal characteristics: age, parity, pre-existing (prepregnancy 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) coding17 for admission diagnoses, comorbidities, length of stay and frequency of admission. Infant characteristics: included birth weight, 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 focused 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.
The analyses were conducted between the two cohorts (women and babies admitted to an RPS and those who were not) utilising contingency tables and results are reported as χ2 analyses. Continuous variables were compared with Student’s t-tests when normally distributed reported as means and SD or with Mann-Whitney U for non-parametric results, reported as medians and IQR. 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 χ2 statistic for all groups as reported 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.
Patient and public involvement
There was no patient involvement in this study as it used de-identified data that had already been gathered.
During the time period there were 1 097 762 births to 355 100 women in NSW. There were 32 991 women admitted 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. When compared with women who were not admitted to RPS, women admitted to RPS were on average 2 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 socioeconomic 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 with 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).
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 with 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 with babies who did not get admitted to an RPS (figure 1). Neonatal outcomes at birth tended to be worse for babies of women admitted to RPS, with more Special Care Nursery/Neonatal Intensive Care (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.
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 (non-specific symptoms peculiar to infancy-excessive crying, irritable infant) (98.7%) and Karitane were more likely to use F51.9/F51.2 (non-organic sleep disorder unspecified/non-organic disorder of the sleep wake cycle) (30.9%) (tables 3 and 4).
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 (tables 5 and 6).
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 in the third time period when compared with 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 with 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.
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.18 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.19 20 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 SEIFA index was higher among 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 with 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.21 This was also the case in this study. Previous research has shown that women who attend RPS appear to 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.22 Social isolation or perceived lack of social support has a significant impact on parenting.23 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.23 Attending to the social support needs of mothers is crucial in reducing the risk or managing maternal depression and anxiety24 and also postpartum post-traumatic stress disorder (PTSD).25
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.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
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. 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).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.
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,29 and their atypical behaviour makes it difficult for parents to read their cues and respond appropriately.30 Mothers of low birth weight infants report more stress related to care of their infants compared with mothers of normal weight infants29 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 SGA infants report their infant as being more fearful and negatively reactive compared with infants born appropriate for gestational age34 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
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 births36 (particularly forceps).37 Women can be affected both physically and psychologically, as well as babies.21 38 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 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.39
The impact of birthing practices on the newborn and early mothering are not insignificant.40 Intrapartum synthetic oxytocin, for example, may disturb sucking and breastfeeding duration in the newborn,41 with animal research showing lasting effects on attachment, social interaction, feeding and sexual behaviour.42 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.43 Unmedicated newborns are more aroused immediately following the birth44 and able to breast feed without assistance if given skin to skin contact and freedom from intrusive procedures.45 46 Following caesarean section there is a significantly longer period of time compared with a normal vaginal birth before a mother touches and holds her newborn47 and this impacts on early breast feeding.48
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. 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%–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.
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 6–7 months following birth, a large Victorian study found 94% of women reported one or more health problems, with tiredness and backache among the most commonly reported.49 Compared with women who had spontaneous vaginal births, women who had instrumental births reported more physical health problems.49 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 post partum, but no significant changes in headache/migraines, sexual problems and depression over the first 6 months.50 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.51 Maternal emotional well-being 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.25
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.14 52 53 The most common ICD 10 codes recorded for babies admitted to RPS were sleep, crying and feeding disorders. The services used more frequently, such as R68.1 (non-specific symptoms peculiar to infancy-excessive crying, irritable infant) (98.7%) or F51.9/F51.2 (non-organic sleep disorder unspecified/non-organic 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.54 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 advises that most of the protective or risk factors associated with infant sleep problems relate to parental management activities.55 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.
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 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 socioeconomic 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. We could not include fathers in the analysis and this is another acknowledged limitation of this study.
This is the largest study to date examining the characteristics of all women and babies 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.
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.
Contributors HGD formulated the study with VS and CF. CT analysed the data. RM, GO’L and JS 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, service needs and co-admissions to residential services of Tresillian and Karitane in NSW from 2000 to 2012.
Competing interests ICMJE uniform disclosure form has been completed. CF, RM, GO'L and JS 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.
Patient consent for publication 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 deidentified information was recorded from the medical records reviewed.
Ethics approval Ethical approval was obtained from the NSW Population and Health Services Research Ethics Committee, Protocol No.2010/12/291. Approval was also granted by the RPS services for release of de-identified data from each site.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data may be obtained from a third party and are not publicly available.