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Postnatal Care Program
Guidelines for Victorian
Health Services
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Postnatal Care Program
Guidelines for Victorian
Health Services
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I you would like to receive this publication in an accessible ormat, please phone 1300 253 942using the National Relay Service 13 36 77 i required, or email: [email protected].
Copyright, State o Victoria, Department o Health, 2012
Published by the Perormance, Acute Programs and Rural Health branch, Victorian Government,
Department o Health, Melbourne, Victoria. This publication is copyright, no part may be reproduced
by any process except in accordance with the provisions o the Copyright Act 1968.
This document is also available in PDF ormat on the internet at: www.health.vic.gov.au/maternitycare
Authorised by the State Government o Victoria, 50 Lonsdale Street, Melbourne.
October 2012 (1210022)
Print managed by Finsbury Green. Printed on sustainable paper.
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1. Introduction 1
2. Purpose 3
3. Scope 5
4. Principles 7
5. Key priorities 9
i. Woman-centred care 9
ii. Culturally appropriate care 13
iii. Collaborative and coordinated care 15
iv. Access to home-based postnatal care 21
v. Sae and high-quality care 25
Appendix. Policy context 29
Reerences 33
Contents
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1
The postnatal period is dened as the period ater the delivery o the baby, usually the rst six weeks
ater birth (Commonwealth o Australia, 2011). Postnatal care may be provided in the acute and
community healthcare sectors or in the womans home.
Care may include routine clinical examination and observation o the woman and her baby, routine
baby screening to detect potential disorders, support or inant eeding, and ongoing provision o
inormation and support (Demott et al., 2006). Postnatal care may be provided by a number o health
proessionals, including registered midwives, registered and enrolled nurses, obstetricians, general
practitioners (GPs) and Aboriginal health workers.
Postnatal care begins immediately ater birth and the primary aims are to provide:
recuperationfromthebirthingprocess
breastfeedingeducationandsupport
parentingeducationandsupport
clinicalcaretopromotethephysicalandpsychologicalhealthandwellbeing
o the woman and her baby.
The Postnatal care program guidelines or Victorian health services (the guidelines) ocuses on the
immediate postnatal period o care in hospital and in the womans home. This period o time is
dependent on the individual needs o the woman, the womans geographical location and the health
service conguration.
The time that women spend in hospital ollowing childbirth has steadily declined. In 200910, theaverage length o stay or a public hospital birth episode was two days or an uncomplicated vaginal
birth and our days or a caesarean section without major complications (Department o Health,
2012). This refects improvements in acute care and the development o alternative and appropriate
care settings, including the womans home.
Whether the setting or care is the hospital or a womans home, the ocus should be on the most
appropriate care setting or each woman. As a result, the average length o hospital stay ollowing
childbirth may continue to decrease. Whether postnatal care is provided in hospital or in the
womans home, it is imperative that the care provided is o the highest standard and meets the
needs o the individual.
These guidelines outline the Victorian Governments expectations o public health services, including
Koori Maternity Services, in the delivery o postnatal care to ensure best quality care is provided to all
women and their babies.
1. Introduction
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The guidelines urther the aims outlined in the Victorian Health Priorities Framework 20122022,
in particular:
developingasystemthatisresponsivetopeoplesneeds
improvingeveryVictorianshealthstatusandexperiences
implementingcontinuousimprovementsandinnovation
increasingaccountabilityandtransparency.
The Department o Health has developed the guidelines in consultation with
the ollowing stakeholders:
MaternityandNewbornClinicalNetwork DepartmentofEducationandEarlyChildhoodDevelopment
associatedprofessionalgroups
representativesfrommetropolitan,ruralandregionalhealthservices.
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3
The guidelines provide direction to support continued reform of
all Victorian public health services responsible for the delivery of
maternity and newborn care, to ensure the needs of the community
are met now and into the future.
It is widely recognised that demand or maternity and newborn care is growing. The guidelines are
intended to assist health services to deliver improved health outcomes or the Victorian community.
Current service delivery and coordination are discussed to inorm health services and the health
service system o the actors that may impact on the delivery o postnatal care.The guidelines identiy key priority areas or improving maternity and newborn care and access
inVictoriaspublichospitals.Eachoftheprioritiesoutlineinitiativesalreadyunderwayandfurther
actions required into the uture.
The key objectives o the guidelines are to:
promotegoodpracticeinthedeliveryofpostnatalcaretowomenandtheirfamilies
identifytheresponsibilitiesofhealthservices,community-basedprovidersandwomen
improvecommunicationbetweenwomen,healthservicesandcommunity-basedproviders
improvecontinuityofcareforwomenacrossthefullrangeofmaternityservices
providescope,directionandauthorityforlocalpolicyandproceduredevelopment.
Public health services are responsible or ensuring compliance with the guidelines.
This includes putting processes in place to:
implementtheguidelines
identifyandprovideappropriateeducationandtrainingopportunitiestohealthservicestaff
who ull the roles and carry out the tasks required by the guidelines
regularlyreviewindividualhealthserviceperformance
validatetheaccuracyandintegrityofreporteddata.
Eachsectionoftheguidelinesincludesinformationtosupportimplementation.Healthservices
should view the sections collectively and, where appropriate, develop their own local policies and
procedures that comply with the guidelines.
2. Purpose
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The guidelines provide direction or all Victorian public health services that are responsible or the
delivery o maternity and newborn services. For the purpose o this document, public health service
reers to all public hospitals and denominational hospitals, public health services and multi-purpose
services established under the Health Services Act 1988.
The guidelines outline the Victorian Governments expectations o public health services in the
delivery o the immediate postnatal period o care in hospital and in the womans home. This period
o time is dependent on the individual needs o the woman, the womans geographical location and
the health service conguration. As the average length o hospital stay ollowing childbirth decreases,
health services should ensure appropriate services are provided to women in their home.
While the care provided by GPs, maternal and child health (MCH) services and other community-
based providers during the postnatal period is not included in the scope o the guidelines, the links
between these and public health services are important and are included in this document.
3. Scope
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The ollowing principles underpin the guidelines and are designed to enable delivery o best available,
evidence-based interventions to optimise the health o the woman and her baby
Postnatalcarewillbewoman-centredtoenablewomentoparticipateininformeddecision
making regarding their own care and the care o their baby.
Postnatalcarewillbeprovidedbyanappropriatelyqualiedmidwife,GPorMCHnurse,
supported by a multidisciplinary team.
Healthserviceswillfacilitatetimelyandequitableaccesstopostnatalcarewithwomenableto
access services as close to home as possible.
Postnatalcarewillbeculturallyappropriateandculturallysafe.
Postnatalcarewillberesponsivetotheoftencomplex,multifacetedneedsofwomenfrom
culturally and linguistically diverse (CALD) backgrounds.
Healthserviceswillworkinacollaborativeandcoordinatedwaywithotherhealthservicesand
community-based providers o maternity and newborn services to optimise womens experiences
and postnatal care outcomes.
Healthserviceswillensurewomenhavetimelyandconsistentaccesstoservicesacrossthe
continuum o care according to their needs.
Healthserviceswillpromotesafeandhigh-qualityoutcomesforwomenandtheirfamilies.
Healthserviceswillcollectandreportaccuratedataonwomensaccesstopostnatalcare.
4. Principles
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i. Woman-centred care
Many women report lower levels o satisaction with the care and support they receive during
the postnatal period than at any other phase o their maternity care (Forster et al., 2005). Feeling
listened to and well supported, and receiving timely and consistent inormation are important actors
contributing to womens satisaction with their postnatal care.
Providing inormation and education relating to the normal physiological changes associated with
childbirth, breasteeding and parenting is a key component o postnatal care that is aimed at giving
women and their amilies the condence to manage the care o their baby.
For a number o rst-time parents, the reality o caring or a baby can be overwhelming and oten
diers rom their expectations. The provision o timely and eective postnatal care and support can
have a signicant impact on the long-term health and wellbeing o women and their amilies.
Postnatal care should be delivered in the most appropriate setting, whether that is in hospital or in
the womans home. Irrespective o the postnatal care setting, it is imperative that the care provided is
o the highest standard and meets the needs o the individual.
Principles
Postnatal care will be woman-centred to enable women to participate in inormed decision making
regarding their own care and the care o their baby.
Postnatal care will be culturally appropriate and culturally sae.
Program guidelines
1. Health services should provide postnatal care that is woman-centred.
Woman-centred care ocuses on a womans unique needs, expectations and aspirations; recognises
her right to sel-determination in terms o choice, control and continuity o care; and addresses her
social, emotional, physical, psychological, spiritual and cultural needs and expectations (Australian
Nursing and Midwiery Council, 2006).
2. Postnatal care planning should commence as early as possible, preerably during the antenatal
care period.
3. Irrespective o the postnatal care setting, health services must ensure that care is woman-centred,
sae and o the highest quality.
4. Health services should plan or postnatal care in partnership with women and their amilies or
signicant others, as determined by the woman hersel.
5. Health services must provide women with timely, appropriate and consistent written inormation
and education to enable inormed decision making.
6. Health services must ensure that women have an individualised home-based postnatal care plan
prior to discharge rom hospital that provides inormation on the care they will receive.
7. Health services should provide breasteeding advice and support according to the Ten Steps
to Successul Breasteeding as specied in the Baby Friendly Health Initiative (World Health
Organization,UNICEF,2009).
5. Key priorities
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Implementation guidance
Inormation and education
Women should be given appropriate and consistent written and verbal inormation and education
relating to the postnatal period. This enables women to make inormed decisions regarding their
care and the care o their baby, and can increase womens condence and satisaction with the care
provided (Newburn & Bhavnani, 2010).
The inormation provided by health services should be given to women as early as possible,
preerably during the antenatal period. It should be easy to understand and communicated in
the womans primary language. Women should also be given the opportunity to discuss and askquestions about the inormation provided with a midwie and/or doctor.
The ollowing inormation should be provided and discussed with women to support decision making
regarding the provision o postnatal care and beyond:
thebirthexperience
psychologicalandsocialadjustmenttoparenthood(forexample,expectations,mood,self-care,
child saety, relationship with partner, contraception)
careofthebaby(forexample,feeding,bathing,handlingandsleep/settlingbabies)
maternalphysicaladjustments(forexample,fatigue,sleep,breastfeeding,breastandbody
changes, sexual health)
familyadjustments(forexample,careofthebaby,siblingsacceptanceofthebaby)
familyenvironment(forexample,housing,employment,safety)
socialsupportandlocalnetworks.
Where appropriate and determined by the woman, written inormation and education should be
provided to her amily and/or signicant others.
Planning
Planning or the postnatal period and beyond should be undertaken in partnership with women as
early as possible. Planning initiated during the antenatal care period can benet women and lead
to higher levels o satisaction with the care provided (Three Centres Consensus Guidelines on
Antenatal Care, 2001).
A written record o planning should be kept by both the woman (Victorian Maternity Record) and
the health service (patient record). The Victorian Maternity Record prompts health proessionals
to discuss planning or postnatal care, and includes a section to document the womans
preerences ater birth.
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At a minimum, a womans postnatal care plan should include inormation relating to:
thewomanspreferredlocationofcare
timingofcare
thewomansexpectationsofcare
contactdetailsofthehealthservicespostnatalcarecoordinatorormidwife
centralcontactdetailsofaMCHservice,closetothewomanshome,towhich
the birth notice has been sent
rolesandresponsibilitiesofboththewomanandthecareprovider(s).
Health services should ask women who they would like to be involved in planning or and deliveringcare throughout the postnatal care period, and where this care should be provided.
Breasteeding
Providing mothers with accurate inormation about the importance o breasteeding to the health
o their baby can result in changes in inant eeding decisions. Health promotion eorts should
emphasise the importance o breasteeding or normal growth and development, and the risks and
costs associated with premature weaning (Berry & Gribble, 2008).
The World Health Organization (WHO) recommends exclusive breasteeding or babies up to six
months o age, with breasteeding continuing alongside complementary oods or up to or beyond
two years o age, as this contributes to optimal physical growth and mental development (WHO,
UNICEF,2009).
There are a number o reasons why women are less likely to breasteed, including less amily
support or breasteeding, less ability to seek help with breasteeding problems, less fexibility with
working arrangements, and concerns about breasteeding in public. Women with lower measures
o education, income and occupational status; younger women; women who are overweight/obese
and women who are smokers are also less likely to breasteed (Amir & Donath, 2008).
According to the 2010Australian National Inant Feeding Survey(Australian Institute or Health
and Welare (AIHW), 2011), almost all Australian babies commence breasteeding but most do
not continue as long as recommended. Although 96 per cent o babies were initially introduced to
breastmilk, 61 per cent were exclusively breasted or less than one month and this progressively
decreased to 15 per cent at around six months o age (AIHW, 2011).
According to the AIHW survey, the main reasons why mothers gave their baby breastmilk were that it
was healthier or child, convenient or helps with mother-baby bonding. Wanting to share eeding
responsibilities with their partner and previously unsuccessul breasteeding experiences were the
two most common reasons or not breasteeding. Many women also elt that ormula was just as
good as breastmilk (AIHW, 2011).
The Baby Friendly Health Initiative(BFHI)developedbytheWHOandUNICEFsetsoutTenSteps
to Successul Breasteeding, which provide the global accreditation standards or health services
providingmaternityandnewborncare(WHO,UNICEF,2009).In200910,26publichospitalsin
Victoria were BFHI accredited (Victorian Government Department o Health, 2012).
TheAustralian national breasteeding strategy 20102015 recognises the biological, health, social,
cultural, environmental and economic importance o breasteeding and provides strategies to
promote breasteeding and complementary oods to 12 months o age and beyond (Commonwealth
o Australia, 2009a).
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Caesarean section
For women who have undergone a caesarean section, postnatal care is important to prevent and,
where necessary, treat inection and post-birth complications.
The rate o caesarean section is growing both in Victoria and nationally. This can be explained,
in part, by actors such as maternal age and medical conditions such as obesity, diabetes and
hypertension (Commonwealth o Australia, 2009b).
In 200809, the rate o caesarean section was 27.9 per cent o all deliveries in Victorian public
health services compared with 39.4 per cent in private hospitals. This rate increased in public health
services to 28.2 per cent in 200910 and 28.4 per cent in 201011. The WHO recommends a
caesarean section rate o 15 per cent (WHO, 1985).
Caesarean sections perormed ollowing an appropriate medical indication are potentially li e-saving
procedures. At the same time, in many settings, women are increasingly undergoing caesarean
sections without any medical indication (Souza et al., 2010).
The World Health Organization Global Survey on Maternal and Perinatal Health (WHOGS) provides
evidence on the relationship between mode o delivery and maternal and perinatal outcomes.
Findings indicate that an increase in rates o caesarean delivery is associated with increased use
o antibiotics postpartum, greater maternal morbidity and mortality, and higher etal and neonatal
morbidity, even ater adjustment or demographic characteristics, risk actors, general medical
and pregnancy associated complications, type and complexity o institution, and proportion o
reerrals (Villar et al., 2006). The need or evidence-based counselling about the risks and benets o
caesarean section or women and their babies is imperative (Boutsikou et al., 2011).
When compared with vaginal delivery, emergency and elective caesarean deliveries are associated
with a decreased rate o exclusive breasteeding. In general, separation o the mother and baby,
post procedure immobility and wound pain may attribute to some womens inability to breasteed
comortably (and thereore exclusively) ollowing a caesarean section (Bodner et al., 2011).
This emphasises the importance o appropriate breasteeding education and support or these
women in the immediate postpartum period.
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Women and their amilies should always be treated with compassion, respect and dignity. The views,
belies and values o the woman and her amily in relation to her care and that o her baby, should be
sought and respected at all times. The woman should be ully involved in the planning o postnatal
care so that care is fexible and tailored to meet her and her babys needs (Demott et al., 2006).
Cultural awareness is an appreciation o cultural, social and historical dierences. Cultural saety
builds on the concept o cultural awareness and is based on the basic human rights o respect,
dignity, empowerment, saety and autonomy (Phiri et al., 2010). Culturally appropriate and culturally
sae care recognises diversity and the dynamic nature o culture.
A culturally competent healthcare system will support eorts to increase the capacity o the system
to design, implement and evaluate culturally and linguistically competent services to address health
disparities among populations rom CALD backgrounds and to promote health and mental health
equity (Department o Health, 2011).
Principles
Postnatal care will be culturally appropriate and culturally sae.
Postnatal care will be woman-centred to enable women to participate in inormed decision making
regarding their own care and the care o their baby.
Postnatal care will be responsive to the oten complex, multiaceted needs o women rom
CALD backgrounds.
Health services will collect and report accurate data on womens access to postnatal care.
Program guidelines
1. To ensure equitable access, postnatal care must be:
culturallyappropriate;withreadilyobtainabletranslatedhealthinformation(forexample,telephone
interpreters, written material sensitive to diering cultures and levels o literacy)
culturallyresponsive;deliveredbyculturallycompetentstaffwithknowledgeofhealthissues
impacting upon dierent population sub-groups, experience in comprehensive assessment and
awareness o support services available or reerral.
2. Health services should ensure that registered midwives and other health proessionals providing
postnatal care are sensitive to the individual needs o women rom CALD backgrounds.
3. Health services should provide women rom linguistically diverse backgrounds with readily
obtainable, translated health inormation, including appropriate interpreting services (ace-to-ace
or telephone), during each postnatal care appointment including home-based visits.
4. Postnatal care must be appropriately coordinated, with good connection to support services and
streamlined processes or reerral.
5. Postnatal care should be innovative and fexible, to meet the complex, multiaceted needs o
women rom CALD backgrounds.
ii. Culturally appropriate care
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Implementation guidance
Cultural competence
Cultural competence requires an understanding and respect or a womans culture, and a
commitment to provide care that appropriately responds to her values, practices and belies.
For example, some Aboriginal and Torres Strait Islander women do not want a prolonged stay in
hospital ollowing the birth o their baby. Health services should ensure systems are strengthened
so that women who discharge early are appropriately supported in the postnatal period. In some
instances, this support may be best provided by an Aboriginal Community Controlled Health Service,
which has an established relationship with the woman.
Health services should provide regular and ongoing training to ensure cultural competency o all sta.
Health services should also embed cultural competence within their quality improvement ramework
to build organisational capacity.
Accountability
Health services will ensure comprehensive and consistent monitoring and management o maternal
and neonatal outcomes data to improve health service planning and delivery or women irrespective
o their cultural, linguistic and socioeconomic background.
This will include improved identication o Aboriginal or Torres Strait Islander status in key
administrative data sets by routinely asking and reporting whether either or both parents o the baby
are o Aboriginal or Torres Strait Islander descent.
Interpreting services
Health services should provide women with access to appropriate interpreting services (ace-to-ace
or telephone). It is the responsibility o health services to arrange an interpreter or required postnatal
care appointments, including home-based visits. This is necessary to ensure that inormation
provided is understood and to enable women and their amilies to ask questions and seek
additional advice.
The Department o Human Services language policyoutlines the requirements or providing access to
proessional interpreting and translating services in Victoria (Department o Human Services, 2005).
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The coordination o maternity and newborn services across the care continuum and throughout
the postnatal period is important to ensure that women and their amilies are able to access timely
and appropriate care that optimises their health and wellbeing and supports amily unctioning and
child development.
Public health services
The current system o maternity and newborn services in Victoria includes three hospitals with
tertiary services (plus a ourth tertiary service dedicated to neonatal and paediatric services) and
a range o metropolitan, large regional and local rural hospitals, providing primary and secondary
maternity care services, as outlined in the Capability ramework or Victorian maternity and newbornservices (Department o Health, 2010).
Victorian public health services are responsible or providing postnatal care to women both in
hospital and or the immediate period ollowing the womans discharge. This period o time is
dependent on the individual needs o the woman, the womans geographical location and the health
service conguration.
Maternal and child health services
It is a requirement under the Child Wellbeing and Saety Act 2005 (Oce o the Child Saety
Commissioner, 2005) that a birth notice is sent by health services to the appropriate local
government authority within 48 hours o the birth.
Localgovernment,inpartnershipwiththeDepartmentofEducationandEarlyChildhood
Development, is responsible or providing community-based MCH services. These services oer
support, inormation and advice regarding parenting and child health and development to amilies
with children up to six years o age.
Upon discharge rom hospital, women are reerred to their local MCH service. The MCH service is
required to contact women to oer and arrange a home visit. In most cases, a MCH nurse will visit
a woman within seven to 14 days o their discharge rom hospital.
Principles
Health services will work in a collaborative and coordinated way with other health services and
community-based providers o maternity and newborn services to optimise womens experiences
and postnatal care outcomes.
Health services will acilitate timely and equitable access to postnatal care with women able to
access services as close to home as possible.
Health services will ensure women have timely and consistent access to services across the
continuum o care according to their needs.
Health services will promote sae and high-quality outcomes or women and their amilies.
iii. Collaborative and coordinated care
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Program guidelines
1. Health services must establish and maintain eective linkages with other health services and
community-based providers o maternity and newborn care to enable women to access
appropriately qualied and skilled health proessionals.
2. Health services must ensure MCH services are appropriately notied o inants and children that
are vulnerable, including those known to Child Protection, Placement and Family Services.
3. Health services must ensure MCH services are appropriately notied o women who are
vulnerable or disadvantaged or who have high needs. Health services must take measures to
ensure continuity o care, a seamless transition between services and that there is no gap incare provision.
4. Health services must clearly document the provision and outcomes o postnatal services in the
womans patient record and Child Health Record to ensure seamless reerral and transer o care.
5. The Child Health Record must provide the woman with suciently detailed inormation to take
with her to her rst MCH appointment.
6. Health services must reer women to other services, where appropriate, that will meet their
individual healthcare needs.
7. Health services must respect womens privacy. Health services must operate within the
parameters o the Health Records Act 2001 with regards to the management, release and
sharing o health inormation between health service providers.
8. Health services should work collaboratively with a womans lead maternity care provider(s) to
ensure early identication and management o physical, emotional, psychological and social
actors that may impact on the health and wellbeing o the woman or her amily during the
postnatal period and beyond.
9. Health services should provide comprehensive assessment and treatment o psychosocial
actors, where indicated, throughout the antenatal and postnatal periods. Health services will
provide support/onward reerral or mothers experiencing postnatal depression and other
health problems.
10. Women should be oered access to postnatal care, irrespective o Medicare or nancialstatus. Health services should notiy women who are ineligible or access to Medicare
subsidised healthcare.
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Implementation guidance
Collaborative and coordinated care
Health proessionals who may be involved in the provision o care during the postnatal period
include registered midwives, registered and enrolled nurses, obstetricians, paediatricians, GPs,
Aboriginal health workers, allied health proessionals and lactation consultants. Care may be
provided by an appropriately qualied midwie, GP or MCH nurse, and be supported by a number
o individual health proessionals orming part o a multidisciplinary team. Care may also include
team consultations.
Health services should promote continuity o care throughout the maternity care pathway and shouldthereore work collaboratively with a womans lead maternity care provider(s). Continuity o care has
been shown to lead to a woman-centred approach to care and consistency in the inormation and
support provided. As a result, women report higher levels o satisaction with their care and a greater
sense o control and saety during the postnatal period (Fereday et al., 2009).
Collaboration between health proessionals and organisations providing care to women and their
amilies during the postnatal period is necessary to acilitate timely access to care that meets
individual needs and expectations (Homer et al., 2009). Successul collaboration is based on the
ollowing elements:
sharedvisionandvalues
agreementandcommitmenttocommongoals soundgovernanceandleadership
recognitionandvaluingofhealthprofessionalsindividualrolesandresponsibilities
willingnesstosharerisks
effectivecommunication
mechanismstoshareinformation.
Assessment o womens health and wellbeing
There is an increasing awareness o the impact o psychosocial actors on the health and wellbeing
o women and their amilies, including the behaviour and cognitive development o children
(Williamson & McCutcheon, 2004).
Health services should ensure that there is a comprehensive assessment process in place
addressing the physical, emotional, psychological and social actors that may impact on the
health and wellbeing o women and their amilies during the postnatal period and beyond (NSW
Department o Health, 2009). The assessment process, where possible, should be initiated during
the antenatal care period and should be ongoing to ensure that new and emerging needs are
identied and managed in a timely manner. The outcomes o assessment should contribute to
planning or the postnatal care period.
Health services should work collaboratively with a womans lead maternity care provider(s) to ensure
early identication and management o physical, emotional, psychological and social actors that
may impact on her health and wellbeing during the postnatal period and beyond.
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Postnatal depression and anxiety
The incidence o clinically signicant symptoms o depression during the postnatal period is
estimated to range between 10 and 15 per cent (Commonwealth o Australia, 2009b). Postnatal
depression can start within one or several months o giving birth. About 40 per cent o women with
postnatal depression had symptoms that started in pregnancy (Matthey et al., 2004).
Risk actors or postnatal depression include a history o mental illness, recent lie stressors (or
example, bereavement, relationship issues) and past or current physical, sexual or psychological
abuse(NICE,2007).Depressionduringthepostpartumperiodisdistinguishedfrombabyblues
by duration and intensity o mood symptoms. Baby blues occurs in 80 per cent o women, with
symptoms resolving within 710 days o childbirth with minimal or no treatment (Pearlstein, 2008).
Recent studies examining anxiety across the antenatal and postnatal periods suggest that as many
as 30 per cent o women may experience signicant symptoms o anxiety (Britton, 2008).
Women with a previous history o a serious mental illness have an increased risk o developing
a recurrence o symptoms during pregnancy or ollowing childbirth. For example, a woman with
a history or amily history o bipolar aective disorder has an overall risk o recurrence o mood
symptoms during pregnancy o 71 per cent. Those who cease taking mood stabiliser medication
during pregnancy are at double the risk (Viguera et al., 2007).
Support vulnerable and at risk children
Health proessionals may encounter vulnerable children and amilies who are at risk o child abuseor neglect, or may witness abuse or neglect that has already occurred or children who are at risk o
signicant harm.
Under the Children Youth and Families Act 2005, some proessionals, such as medical practitioners,
nurses, police ocers and school teachers, are legally obliged to report suspected child abuse. In
addition, any person who believes on reasonable grounds that a child needs protection can make a
report to the Victorian Child Protection Service.
Health services providing postnatal care have a key role to play in the care and protection o
vulnerable children through early identication o child abuse and neglect. By working with
community services, Child Protection and the justice system, health services can contribute to
the provision o early intervention to help meet the needs o vulnerable babies, children and young
people at risk o harm.
The Department o Health has produced and distributed a best practice ramework, Vulnerable
babies, children and young people at risk o harm: Best practice ramework or acute health services
(Department o Health, 2006), that provides inormation and guidance or health services on issues
relating to children and young people at risk o abuse and neglect.
Health proessionals working together to keep children sae (Victorian Forensic Paediatric Medical
Service) is an online resource designed to assist health proessionals working in Victorian hospitals
and community settings to identiy vulnerable children; respond to situations where abuse or neglect
is suspected; and understand the child protection service system.
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Medicare ineligible patients
Medicare ineligible patients are individuals within Australia who are not eligible or Medicare and are
unable to receive ree public hospital services under the National Healthcare Agreement and the
National Health Reorm Agreement. Medicare ineligible patients are generally temporary entrants to
the country, including tourists, international students and temporary workers.
Medicare ineligible patients seeking treatment or maternity care can access treatment at a public
hospital as a private patient. Women seeking care should be encouraged to discuss the likely ees
with the hospital.
The National Health Reorm Agreement (COAG, 2011) allows states and territories to charge
Medicare ineligible patients or services provided by public hospitals. Current Department o Health
policy advises that ees or ineligible patients be set to achieve ull cost recovery. Health services
may charge Medicare ineligible patients at the ull cost recovery rate and manage debt processes to
ensure appropriate revenue is collected to recover costs.
Under current Department o Health policy, Medicare ineligible asylum seekers are classied as
public patients and hospitals are unable to charge these patients. Medicare ineligible asylum seekers
are provided with the ull medical care they require and health services are paid the relevant public
price by government or their treatment.
Patient consent and confdentiality
Health services should obtain a womans consent* or reerral and ensure that she has been givenadequate inormation regarding the nature o the reerral.
Health services must respect womens privacy and must operate within the parameters o the
Health Records Act 2001 with regards to the management, release and sharing o a patients health
inormation between health service providers.
Reerral guidelines
Women who would benet rom other specialist services (or example, physiotherapy, psychology,
lactation consultants) during the postnatal period and beyond should be reerred to an appropriate
service provider located as close as possible to the womans home.
* Consent may be express or implied. Signing a consent orm is one orm o express consent. Consent is implied rom a
persons actions, such as when rolling up a sleeve to receive a fu vaccine.
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A reerral or transer o a womans care to another health service or community-based service
provider should be written and should contain relevant and sucient inormation to appropriately
prioritise and manage a womans wait or services and her care at the rst appointment
(Department o Health unpub). The ollowing is suggested as the basic content that should
be included in a reerral:
thewomansdemographics(forexample,contactdetails,dateofbirth,andinformationabout
special needs)
referrerdetails
primarymaternitycareprovider(s)(forexample,GP,specialistobstetrician,registeredmidwife)
healthservicedischargesummaryincludingrelevanthistory,currentmedications,postnatalcareplan and reason or reerral
relevantinvestigationresults
priorityforcare,ifrelevant.
The Service Coordination Tool Templates (SCTT) (Department o Health, 2009) were developed
to acilitate and support service coordination. The SCTT support the collection and recording o
initial contact, needs identication, reerral and care planning inormation in a standardised way.
This can improve communication and inormation sharing to support better outcomes or women
and their amilies.
Record keeping
Health services should keep comprehensive written records o postnatal care, including a womans
consent or care. This is important to ensure consistency o inormation provided and timely transer
and ollow-up o care.
Guidance on the collection and storage o patient inormation is available rom the Public Records
Oce o Victoria (http://www.prov.vic.gov.au).
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Postnatal care, irrespective o setting, is ocused on the needs o the mother and supporting her to
care or her baby. Postnatal home-based care should be provided by a registered midwie rom the
birth hospital where possible, and supported by a number o individual health proessionals orming
part o a multidisciplinary team. However, home-based care may be transerred to the service o a
dierent hospital, a Koori Maternity Service, the Royal District Nursing Service or a private nursing
agency to better suit the individual needs o a woman, particularly when located closer to the
womans home.
Home-based models o postnatal care are becoming increasingly important in assisting women to
transition rom hospital to home, and or providing them with care and advice in the most appropriate
care setting or their needs. For many women, home can also be a more relaxed, convenient andprivate environment or recovery rom childbirth and or the establishment o breasteeding.
As a minimum requirement, ollowing discharge, public health services should oer women at least
one postnatal visit in her home. Additional home visits are provided on the basis o individual clinical
and psychosocial needs.
Principles
Health services will acilitate timely and equitable access to postnatal care with women able to
access services as close to home as possible.
Health services will work in a collaborative and coordinated way with other health services and
community-based providers o maternity and newborn services to optimise womens experiences
and postnatal care outcomes.
Health services will promote sae and high-quality outcomes or women and their amilies.
Health services will collect and report accurate data on womens access to postnatal care.
Program guidelines
1. Health services providing intrapartum care must oer women home-based postnatal care prior to
their discharge home.
2. Health services will ensure the health and saety o all sta members providing home-based care,
in accordance with relevant legislation.
3. Following discharge home rom hospital, a suitably qualied health proessional, preerably
a registered midwie, should provide at least one postnatal home-based visit tailored to the
individual requirements o the woman. For many women, this visit will be required within
24 hours o discharge.
4. Health services must provide multiple postnatal home-based visits to women with identied
clinical and psychosocial needs during the immediate postnatal period o care. This includes local
health services that are sub-contracted to provide postnatal home-based care. The period o
time and the number o visits required is dependent on the individual needs o the woman, the
womans geographical location and the health service conguration.
iv. Access to home-based postnatal care
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5. Women who should be considered or multiple postnatal home visits include:
rst-timemothers
youngwomen,includingteenagers
womenwithoutasupportnetwork
AboriginalandTorresStraitIslanderwomen
womenwithadisability
womenwithsubstanceabuseissues
womenknowntochildprotection
womenwhoexperiencedbirthorpost-birthcomplications
womenexperiencingbreastfeedingdifculties
womenwhohavenotyetreceivedantenatalcare
womenwithpsychosocialissues.
6. Sub-contracted health services, including Aboriginal Community Controlled Health Organisations
with a Koori Maternity Service, are responsible or arranging appropriate remuneration with the
birthing hospital or any services provided.
Implementation guidance
Failure to be present at the time o visit
Health services should make reasonable attempts to contact women who are not present on the day
o an agreed postnatal home-based visit. At a minimum, health services should attempt to contact
the woman and her nominated GP to arrange another visit.
Women may choose to decline postnatal home-based care ollowing discharge home rom hospital.
Where care is declined, health services should document this in the womans patient record.
Health services should exercise discretion to avoid disadvantaging women in the case o hardship,
misunderstanding and other extenuating circumstances.
Access in rural and regional areas
Advances in inormation and communication technologies have improved access to healthcare
and advice or geographically dispersed individuals. Where a ace-to-ace home-based visit is not
possible, health services should consider alternative models o service delivery when providing
postnatal care to women in rural and regional areas. For example, providing women with the ability
to access support via telephone in conjunction with home-based visits has been shown to improve
breasteeding duration and exclusivity and decrease symptoms o postnatal depression (Dennis &
Kingston, 2008; Fereday et al., 2009).
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Sub-contracting service delivery
Health services may restrict service delivery to individuals residing within a geographical area. Health
services should, however, demonstrate fexibility to accommodate the exceptional needs o women
residing outside o this area.
Where health services determine that a woman lives outside o their easible geographical area, the
provision o postnatal home-based care should be sub-contracted to a local health service, private
provider or district nursing service. Sub-contracted health services, including Aboriginal Community
Controlled Health Organisations with a Koori Maternity Service, are responsible or arranging
appropriate remuneration with the birthing hospital or any services provided.
In some cases, sub-contracting o postnatal home-based care should be arranged to maintain
continuity o care and/or carer. Continuity o care reers to a consistent organisational structure
around which care is provided (or example, team based model o maternity care). Continuity o carer
reers to care provided by a primary midwie whom the woman has previously met and is amiliar
with (or example, caseload model o maternity care) (Homer et al., 2002).
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Health services should ensure women and their babies have access to sae, high-quality maternity
services. Whether postnatal care is provided in hospital or in the womans home, it is imperative that
the care provided is o the highest standard and meets the needs o the individual.
In addition to ensuring the health and saety o women accessing postnatal care, health services
should also consider the occupational health and saety o all health proessionals responsible or
providing postnatal care.
Principles
Health services will promote sae and high-quality outcomes or women and their amilies.
Health services will collect and report accurate data* on womens access to postnatal care.
Program guidelines
1. Health services must provide postnatal care within a sound quality and saety ramework.
2. Health services must promote evidence-based practices.
3. Health services must provide sta with access to regular and ongoing education and training that
supports their scope o practice.
4. Health services must collect and report data on womens access to postnatal care including
home-based care.
5. Health services must provide health proessionals delivering postnatal home-based care with
the necessary equipment and training to protect their own health and wellbeing and enable the
delivery o timely and appropriate care.
6. Health services must comply with accepted legislation, including the Occupational Health and
Saety Act 2004.
7. In determining appropriate care or women with co-morbid conditions, health services should
ensure appropriate physical and service delivery capabilities, including appropriate workorce
capability and risk management strategies.
Implementation guidancePolicies and procedures
Health services should have written policies and procedures that address occupational health and
saety considerations that could impact on health proessionals responsible or providing postnatal
care, including home-based visits (or example, driving in hazardous weather conditions, bushre
training and the use o a car as an emergency vehicle).
Health services should also have written protocols relating to the treatment o women and their
amilies during the postnatal care period.
v. Safe and high-quality care
* data elements specied under Perormance reporting
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Education and training
Health services should ensure that health proessionals employed to deliver postnatal care are
appropriately qualied and credentialled. A qualied and skilled workorce is imperative to the
provision o sae and high-quality postnatal care that refects current, evidence-based practices.
Health services should ensure that all health proessionals providing postnatal home-based care
have undertaken adequate training to make decisions regarding the saety o the environment in
which they are to provide care.
Perormance reporting
Health services should report annually against the Department o Healths maternity servicesperormance indicators (Department o Health, 2012). The perormance indicators relevant to
postnatal care are:
MaternityIndicator6Rateofwomenreferredtopostnataldomiciliarycareorhospital-in-the-
home in Victorian public hospitals
MaternityIndicator8NumberofWHOTenStepstoSuccessfulBreastfeedingachievedin
Victorian public hospitals
The ollowing three indicators are in development and will replace the current breasteeding support
indicator (Maternity Indicator 8):
MaternityIndicator8bBreastfeedinginitiationinVictorianpublichospitals
MaternityIndicator8cUseofinfantformulainVictorianpublichospitals
MaternityIndicator8dFinalfeedbeingtakenexclusivelyfromthebreastin
Victorian public hospitals
It is expected that all women will be reerred to postnatal home-based care or hospital in the home
(HITH). Women eligible or HITH must meet the criteria o the Victorian hospital admission policy
(Department o Health, 2011b).
Health services in scope to collect specialist (outpatient) clinic data through the Victorian Integrated
Non-Admitted Health (VINAH) data set should report this to the Department o Health as per
the specications (Victorian Government Health Data Standards and Systems). The VINAH data
collection was rolled out to outpatient clinics on 1 July 2011 or implementation rom 1 July 2012.
Risk actors associated with pregnancy
The most common pregnancy complications are obesity, hypertension, diabetes mellitus,
cardiovascular disease (CVD) and placental abnormalities (Segev et al., 2011). Uncontrolled
conditions such as gestational diabetes and chronic hypertension can increase the risk o maternal
and etal/neonatal complications.
Many women who need assisted reproductive technology because o inertility are older than the
average pregnant woman and the risks or chronic diseases such as obesity, diabetes mellitus,
chronic hypertension, CVD and malignancy greatly increase with maternal age.
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Women who are overweight or obese have increased risks o experiencing pregnancy complications
such as gestational diabetes, pregnancy-induced hypertension and wound inection. Overweight and
obese women are also at greater risk o giving birth to a preterm baby (less than
37 weeks) or low birth weight baby (less than 2500g) compared with women o normal weight range
(McDonald et al, 2010).
In recognition o the additional risks posed by actors such as obesity during the postnatal period,
specic measures o routine care may be required, such as weight management strategies.
Health services should work to strengthen systems or health protection, health promotion and
preventive healthcare, including appropriate assessment and management o women with risk
actors and their baby.
Occupational health and saety
Health services should have written policies and procedures that address occupational health and
saety considerations that could impact on health proessionals responsible or providing postnatal
care, including home-based visits (or example, driving in hazardous weather conditions, bushre
training and the use o a car as an emergency vehicle).
Specically, health services should ensure:
promotionofappropriatestandardsinoccupationalhealthandsafetyandwelfareandinjury
management
useofeffectivepreventionstrategiesandinjurymanagementpractices integrationofoccupationalhealthandsafetyacrossallaspectsofbusinessoperations,systems
o work and procedures (Department o Human Services, 2003).
The Occupational Health and Saety Act 2004 (OHS Act) highlights the principles that all employers
and employees should apply in building and maintaining sae workplaces.
WorkSae Victoria, a statutory authority o the Victorian State Government, works with employers
and employees to ensure the appropriate inormation, guidance and assistance is available to
support compliance with the OHS Act.
Working saely in visiting health services (WorkSae Victoria, 2011a) is a publication developed
or healthcare providers involved in the assessment and treatment o clients in their homes and
other community settings. The publication covers health and saety basics, with a ocus on
occupational violence and manual handling.
Home care occupational health and saety compliance kit(WorkSae Victoria, 2011b) describes
the seven most common hazardous tasks that cause workplace injuries in the home care sector.
It includes seven health and saety solutions to outline ways to control the risks associated with
these tasks.
Inormation includes measures or identiying hazards and risks, and implementing control measures
to eliminate, isolate or substitute the source o the risk. When a clients home is deemed to be
unsae, advice is provided or suspending visits or providing visits in a saer environment such as at a
local hospital outpatient clinic.
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There are a range o state and national policy rameworks that provide guidance to health services
on the principles underpinning maternity and newborn care including postnatal care.
Victorian context
Victorian Health Priorities Framework 20122022
In May 2011, the Victorian Government released the Victorian Health Priorities Framework
20122022, which provides the blueprint or planning and development o priorities or the
Victorian healthcare system or the coming decade.
The ramework is the basis or three supporting plans: the Metropolitan Health Plan, Rural andRegional Health Plan and Health Capital and Resources Plan.
The ramework establishes the key outcomes, attributes and improvement priorities or the Victorian
healthcare system across seven priority areas:
developingasystemthatisresponsivetopeoplesneeds
improvingeveryVictorianshealthstatusandexperiences
expandingservice,workforceandsystemcapacity
increasingthesystemsnancialsustainabilityandproductivity
implementingcontinuousimprovementsandinnovation
increasingaccountabilityandtransparency
utilisinge-healthandcommunicationstechnology.
Metropolitan Health Plan
The Victorian Government published the Metropolitan Health Plan in May 2011. The plan articulates
the long-term planning and development priorities or metropolitan Melbourne and statewide health
services throughout the next decade. It indicates that a Reugee Health and Wellbeing Plan will be
developed and available in 2012, which will increase the capacity o the healthcare system to design,
implement and evaluate culturally and linguistically competent services to address health disparities
among populations rom CALD backgrounds.
Rural and Regional Health Plan
The Victorian Government published the Rural and Regional Health Plan in December 2011.This plan will drive the development o key actions that will deliver services in rural and regional
Victoria that are more responsive to peoples needs and are rigorously inormed and inormative.
Health Capital and Resources Plan
The Health Capital and Resources Plan will be available in 2012 and will apply the overarching
Victorian Health Priorities Framework 20122022 to the specic context and challenges o rural
and regional Victoria.
Victorian Public Health and Wellbeing Plan 20112015
The Victorian Public Health and Wellbeing Plan aims to improve the health and wellbeing o all
Victorians by engaging communities in prevention, and by strengthening systems or health
protection, health promotion and preventive healthcare across all sectors and levels o government.
The plan is a companion document to Victorian Health Priorities Framework 20122022.
Appendix. Policy context
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Future directions or Victorias maternity services
Future directions or Victorias maternity services (2004) provides the policy ramework that sets the
direction or the provision o maternity care in Victoria. The policy refects the belie that birthing is a
normal process and, where possible, should be located close to the mothers home.
The principles underpinning the policy are:
Womenhaveinformedchoice,continuityandsafetyintheirpregnancy,birthingand
postnatal experiences.
Primarymaternitycareisthemostappropriatemodelofcareforthenormallifeevents
o pregnancy and birthing.
Accesstoappropriatespecialisedcarewhenrequiredisintegraltoprovidingsafe,
high-quality maternity care.
Acollaborative,multidisciplinaryteamapproachtotheprovisionofmaternitycarerequires
education, training and development.
Capability ramework or Victorian maternity and newborn services
The Capability ramework or Victorian maternity and newborn services (2011) delineates the role
o maternity and newborn services and denes the minimum standards required to deliver dierent
levels o care. There are six levels o care, which can be broadly grouped as:
Primarymaternitycareservices(levels1,2and3)providecaretowomenwithlow
or normal risk pregnancies and births.
Secondarymaternitycareservices(levels13,4and5)providecaretowomenwith
medium risk pregnancies and births with moderate complications.
Tertiarymaternitycareservices(levels15and6)providecaretowomenwithcomplex
pregnancies and births requiring neonatal intensive care.
Perinatal Emotional Health Program
In2010,theDepartmentofHealthestablishedthePerinatalEmotionalHealthProgramtoimprove
early identication and treatment o women at risk o or experiencing depression during the antenatal
and postnatal periods. The program currently employs 16 mental health nurses or equivalent across
rural and regional Victoria to provide clinical assessment and treatment in maternity services,
MCH services or in womens homes. A pilot o a similar program or metropolitan Melbourne isplanned or 2012.
Continuity o Care: A communication protocol or Victorian Public Maternity
Services and the Maternal and Child Health Service
Continuity o Care: A communication protocol or Victorian Public Maternity Services and the
Maternal and Child Health Service (2004) provides a ramework to support eective communication
between health services, MCH services and other services providing care to women and their
amilies. The ramework was developed through a partnership between the departments o
EducationandEarlyChildhoodDevelopment,HealthandHumanServices,andtheMunicipal
Association o Victoria.
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Programs to support vulnerable and disadvantaged women
In Victoria, a number o programs have been established to support vulnerable and disadvantaged
pregnant women and their amilies during the postnatal period. These include:
Healthy Mothers Healthy Babies program which supports access to appropriate services during
the antenatal and postnatal care period, and provides key health promotion messages to support
healthy behaviours in pregnancy and beyond. The program is available to women up to six weeks
post-childbirth.
KooriMaternityServicesprovideculturallyappropriatematernitycareandsupporttoAboriginal
and Torres Strait Islander women with the principle ocus o increasing access to antenatal
care and postnatal support, and liaising with public maternity services. There are currently 11
Aboriginal community controlled health organisations providing the service.
EnhancedMCHServicerespondstotheneedsofchildrenandfamiliesatriskofpooroutcomes.
The service provides a more intense level o support than the universal MCH service to amilies
with one or more risk actors, including drug and alcohol issues, mental health issues, amily
violence issues, homelessness and low income, socially isolated and single-parent amilies
(DepartmentofEducationandEarlyChildhoodDevelopment,2011).
Care o the obese pregnant woman and weight management in pregnancy
clinical guideline
Care o the obese pregnant woman and weight management in pregnancyclinical guideline aims
to promote and acilitate standardisation and consistency in practice in the care o obese women in
pregnancy. The guidelines recognise the:
potentialcomplicationsassociatedwithobesityinpregnancy
importanceofappropriateweightmanagementinpregnancy
needforconsistencyofpracticeinmanagingobesityinpregnancy
needforappropriateworkforceandworkplacecapabilitytomanageobesityinpregnancy.
National context
National Maternity Services Plan
The National maternity services plan (2010) recognises the importance o maternity serviceswithin the health service system and provides a strategic national ramework to guide policy and
program development across Australia over the next ve years. The plan is underpinned by the
ollowing principles:
Maternitycareplacesthewomanatthecentreofherowncare.Suchcareiscoordinated
according to the womans needs, including her cultural, emotional, psychosocial and clinical
needs close to where they live.
Maternitycareenablesallwomenandtheirfamiliestomakeinformedandtimelychoicesin
accordance with their individual needs. The planning and provision o maternity care is inormed
by women and their amilies.
WomenandfamiliesinruralandremoteAustraliahaveimprovedandsustainableaccessto
high-quality, sae, evidence-based maternity care which incorporates access to appropriate
medical care i complications arise.
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GovernmentsandhealthservicesworktoreducethehealthinequalitiesfacedbyAboriginaland
Torres Strait Islander mothers and babies or other disadvantaged populations.
Maternityservicesoffercontinuityofcareacrossthepregnancyandbirthingcontinuumasakey
element o quality maternity care or all women and their babies.
Maternitycarewillbeprovidedforallwomenandtheirbabieswithinawellnessparadigm,utilising
primary healthcare principles whilst recognising the need to respond to emerging complications in
an appropriate manner.
Thepotentialofmaternityhealthprofessionalsismaximisedtoenablethefullscopeoftheir
specic knowledge, skills and attributes to contribute to womens maternity care.
Maternityservicesprovidehigh-quality,safe,evidence-basedmaternitycarewithinanexpandedrange o sustainable maternity care models.
Maternityservicesarestaffedbyanappropriatelytrainedandqualiedmaternityworkforce
sucient to sustain contemporary evidence-based maternity care.
Maternityservicesoperatewithinanationalsystemformonitoringperformanceandoutcomes
and guiding quality improvement.
Australian National Breasteeding Strategy
TheAustralian national breasteeding strategy 20102015 (2009) recognises the biological, health,
social, cultural, environmental and economic importance o breasteeding and provides a ramework
o priorities or Australian governments at all levels to protect, promote, support and monitor
breasteeding. The objective o the strategy is to increase the percentage o babies who are ullybreasted rom birth to six months o age, with continued breasteeding and complementary oods to
12 months o age and beyond.
National Perinatal Depression Initiative
The National Perinatal Depression Initiative aims to improve prevention, early detection and treatment
o antenatal and postnatal depression. The initiative provides routine and universal screening or
depression or women during the perinatal period; ollow-up treatment and support or women who
are at risk o or experience perinatal depression; training and development o health proessionals
to assist them in screening and identiying women at risk o experiencing perinatal depression;
and research and data collection into prevention activities and the provision o services to meet
womens needs.As part o this initiative, the National Health and Medical Research Council Clinical practice guidelines
or depression and related disorders anxiety, bipolar disorder and puerperal psychosis in the
perinatal period(2011) were developed by beyondblue to assist health proessionals working in
primary and maternity care to identiy and treat mental health problems in the perinatal period.
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Amir LH & Donath SM 2008, Socioeconomic status and rates o breasteeding in Australia:
evidence rom three recent national health surveys, Med J Aust, 189(5) pp. 254-56.
Australian Institute o Health and Welare (AIHW) 2011,2010 Australian national inant eeding
survey: indicator results.Cat.no.PHE156.AIHW,Canberra
Australian Nursing and Midwiery Council 2006, National Competency Standards or the Midwie,
Berry NJ & Gribble KD 2008, Breast is no longer best: promoting normal inant eeding, Maternal
and Child Nutrition, 4, pp. 7479.
Bodner K, Wierrani F, Grnberger W & Bodner-Adler B 2011, Infuence o the mode o delivery onmaternal and neonatal outcomes: a comparison between elective cesarean section and planned
vaginal delivery in a low-risk obstetric population,Arch Gynecol Obstet, 283, pp.11931198.
Boutsikou T & Malamitsi-Puchner A 2011, Caesarean section: impact on mother and child,
Acta Paediatrica, 100(12), pp.151822.
Britton J 2008, Maternal anxiety: Course and antecedents during the early postpartum period
Depression and Anxiety, 25, pp.793-99.
Child Wellbeing and Saety Act year? .
Children, Youth and Families Act 2005, Act No. 96/2005 .
Commonwealth o Australia 2009a, on behal o the Australian Health Ministers Conerence
Australian National Breasteeding Strategy 20102015
Commonwealth o Australia 2009b, Improving maternity services in Australia: The report o
the Maternity Services Review
Commonwealth o Australia 2011, on behal o the Australian Health Ministers Conerence
National Maternity Services Plan,
Council o Australian Governments 2011, National Health Reorm Agreement, .
DemottK,BickD,NormanR,RitchieG,TurnbullN,AdamsC,BarryC,ByromS,EllimanD,
Marchant S, Mccandlish R, Mellows H, Neale C, Parkar M, Tait P & Taylor C 2006, Clinical guidelines
and evidence review or post natal care: routine post natal care o recently delivered women
and their babies, National Collaborating Centre or Primary Care and Royal College o General
Practitioners, London.
Dennis CL & Kingston D 2008 A systematic review o telephone support or women during
pregnancy and the early postpartum period, Journal o Obstetric, Gynaecologic and Neonatal
Nursing, 37(3), pp. 301-314.
DepartmentofEducationandEarlyChildhoodDevelopment2011,Maternal and Child HealthService guidelines, State Government o Victoria, Melbourne. .
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