Professor Deb Loxton

In Australia, nearly half of births involve labour interventions. Prior research in this area has relied on cross-sectional and administrative health data and has not considered biopsychosocial factors. The current study examined direct and indirect associations between biopsychosocial factors and labour interventions using 19¿years of population-based prospective data. The study included singleton babies among primiparous women of the 1973¿1978 cohort of the Australian Longitudinal Study on Women¿s Health. Data from 5459 women who started labour were analysed using path analysis. 42.2% of babies were born without intervention (episiotomy, instrumental, or caesarean delivery): Thirty-seven percent reported vaginal birth with episiotomy and instrumental birth interventions, 18% reported an unplanned caesarean section without episiotomy and/or instrumental interventions, and 3% reported unplanned caesarean section after episiotomy and/or instrumental interventions. Vaginal births with episiotomy and/or instrumental interventions were more likely among women with chronic hypertension (RRR(95%-CI):1.50(1.12¿2.01)), a perceived length of labour of more than 36¿h (RRR(95%-CI):1.86(1.45¿2.39)), private health insurance (RRR(95%-CI):1.61(1.41¿1.85)) and induced labour (RRR(95%-CI):1.69(1.46¿1.94)). Risk factors of unplanned caesarean section without episiotomy and/or instrumental birth intervention included being overweight (RRR(95%-CI):1.30(1.07¿1.58)) or obese prepregnancy (RRR(95%-CI):1.63(1.28¿2.08)), aged = 35¿years (RRR(95%-CI):1.87(1.46¿2.41)), having short stature (< 154¿cm) (RRR(95%-CI):1.68(1.16¿2.42)), a perceived length of labour of more than 36¿h (RRR(95%-CI):3.26(2.50¿4.24)), private health insurance (RRR(95%-CI):1.38(1.17¿1.64)), and induced labour (RRR(95%-CI):2.56(2.16¿3.05)). Prevention and management of hypertension, diabetes, and obesity during preconception and/or antenatal care are keys for reducing labour interventions and strengthening the evidence-base around delivery of best practice obstetric care.

Background: Given chronic disease is increasing among young women and unintended pregnancies among these women are associated with poor maternal and fetal outcomes, these women would benefit from effective preconception care. However, there is a lack of understanding of how these women use or don¿t use contraception to inform such interventions. This study examined patterns of contraceptive use among an Australian cohort of young women and investigated the influence of chronic disease on contraceptive use over time. Methods: Using data from 15,244 young women from the Australian Longitudinal Study on Women¿s Health (born 1989¿1995), latent transition analysis was performed to identify distinct contraceptive patterns among women who were at risk of an unintended pregnancy. Multinomial mixed-effect models were used to evaluate the relationship between contraceptive combinations and chronic disease. Results: Contraceptive use for women with cardiac and autoinflammatory diseases differed to women without chronic disease over the observation period. Compared to women without chronic disease using the pill, women with cardiac disease had double the odds of using ¿other¿ contraception and condoms (OR = 2.20, 95% CI 1.34, 3.59) and a modest increase in the odds of using the combined oral contraceptive pill and condoms (OR = 1.39, 95% CI 1.03, 1.89). Compared to women without chronic disease who used the pill, women with autoinflammatory disease had increased odds of using LARC and condoms (OR = 1.58, 95% CI 1.04, 2.41), using ¿other¿ contraception and condoms (OR = 1.69, 95% CI 1.11, 2.57), and using the¿combined oral contraceptive pill and condoms (OR = 1.38, 95% CI 1.09, 1.75). No differences in contraceptive patterns over the observation period were found for women with asthma or diabetes when compared to women without chronic disease. Conclusion: The findings identified a need for effective contraceptive counselling as part of routine chronic disease care and improved communication between health¿care providers and women with chronic disease to improve young women¿s contraceptive knowledge and agency in contraceptive choice, particularly for those with cardiac or autoinflammatory conditions. This may be the key to reducing high-risk unintended pregnancies among this vulnerable population.

This study aims to estimate the prevalence and correlation of household levels of water, sanitation, and hygiene (WASH), including the identification of areas where WASH facilities are unimproved in Nepal. The study population was 11,040 household heads, using the data collected in the Nepal Demographic and Health Survey 2016. Logistic regression analysis was performed and crude odds ratios (OR) with 95% confidence intervals (CI) using a 0.05 significance level are presented. Getis¿Ord Gi* statistics were used to identify the hot and cold spot areas of unimproved WASH. GPS locations of WASH points were used for spatial analysis. Approximately 95% of households had an improved water source, 84% had improved sanitation facilities, 81% had a fixed place for hand-washing, and 47% had soap and water. Education, wealth, and ecology were significantly associated with WASH. The people from the hills were less likely to have an improved water source (OR = 0.32; 95% CI: 0.16¿0.64) than those from the plain. Households with a poor wealth index had 78% lower odds of having an improved water source compared to households with a rich wealth index. Respondents from Madhes Province had lower odds (OR = 0.15; 95% CI: 0.08¿0.28) and Gandaki Pradesh had the highest odds (OR = 2.92; 95% CI: 1.52¿5.61) of having improved sanitation facilities compared to Province 1. Respondents aged 35¿44 years had higher odds (OR = 1.16; 95% CI: 1.04¿1.29) of having soap and water available compared to those aged 45 years and older. Education and geographical disparities were the factors associated with having reduced access to WASH. These findings suggest the need to focus on advocacy, services, and policy approaches.

Background: This study aimed to analyse national health facility burden of preeclampsia/eclampsia and its regional distribution in Ethiopia. This evidence is an important aspect to work towards reducing maternal and newborn complications. Methods: This study uses data from the 2016 Emergency Obstetrics and Newborn Care (EmONC) survey which national census of public and private health facilities that provided delivery services. Cross-tabulation of variables was conducted based on region, location, types of health facility, and the management authority of health facilities. Spatial analysis was conducted to investigate spatial regional distribution of preeclampsia/eclampsia. Results: A total of 3804 health facilities were included in the survey. Nationally, preeclampsia/eclampsia contributes to 5.9% of all maternal complications and 10.5% of maternal deaths. While 82% of total deliveries were reported from health centres, hospitals and specialised centres reported nearly 10 times more cases of PE/E (23 per 1000 deliveries) than health centres (2.4 per l000 deliveries). The highest number of preeclampsia/eclampsia cases were reported in Addis Ababa and the Harari region where there were 32 and 24 cases per 1000 deliveries, respectively. A substantial proportion of direct obstetrics complications due to preeclampsia/eclampsia were reported from Afar, Somali, Harari and the Benishangul Gumuz regions (19.9%, 18.0%, 12.8%. 11.5%, respectively). Conclusions: Preeclampsia/eclampsia contributed to a high proportion of maternal complications and death. Disproportionally, the highest burden of preeclampsia/eclampsia was reported in developing regions of Ethiopia. These region's health facilities' effort on case detection, reporting and evidence generation should be strengthened to inform policy especially those located in rural location.

Background Caesarean section has a significant role in reducing maternal and neonatal mortality. A linked analysis of population and health facility data is valuable to map and identify caesarean section use and associated factors. This study aimed to identify geographic variation and associated factors of caesarean delivery in Ethiopia. Method Linked data analysis of the 2016 Ethiopia Demographic and Health Survey (EDHS) and the 2014 Ethiopian Service Provision Assessment Plus (ESPA+) survey was performed. Spatial analysis was conducted to identify geographic variations and factors associated with caesarean delivery. Hierarchical Bayesian analysis was also performed to identify factors associated with caesarean delivery using the SAS MCMC procedure. Results Women¿s age and education, household wealth, parity, antenatal care (ANC) visits, and distance to caesarean section facility were associated with caesarean delivery use. Women who had =4 ANC visits were 4.67 (95% Credible Interval (CrI): 2.17, 9.43) times more likely to have caesarean delivery compared to those who had no ANC visits. Women who had education and were from rich households were also 2.80 (95% CrI: 1.83, 4.19) and 1.80 (95% CrI: 1.08, 2.84) times more likely to have caesarean deliveries relative to women who had no education and were from poor households, respectively. A one-kilometer increase in distance to a caesarean section facility was associated with an 88% reduction in the odds of caesarean delivery (Adjusted Odds Ratio (AOR) = 0.12, 95% CrI: 0.01, 0.78). Hotspots of high caesarean section rates were observed in Addis Ababa, Dire Dawa, and the Harari region. In addition, women¿s age at first childbirth and =4 ANC visits showed significant spatially varying relations between caesarean delivery use across Ethiopia. Conclusion Caesarean section is a lifesaving procedure, and it is essential to narrow disparities to reduce maternal and neonatal mortality and avoid unnecessary procedures.

The aim of this study was to assess the long-term risk for mortality and incident dementia associated with exposure to intimate partner violence (IPV) at any time over the life course. Data were taken from the Australian Longitudinal Study of Women¿s Health, a population-based cohort study initiated in 1996. Analysis is based on 12,085 community-dwelling women aged 70 to 75 years at baseline from all states and territories. Self-reported exposure to violence was separated into historical (any time before baseline), current (past 12 months), or both. Date of death was obtained from the National Death Index, and dementia status was self-reported or obtained from administrative data. We modeled mortality risk using Cox regression, and risk for incident dementia using Fine-Gray proportional hazards modeling with death as a competing risk. Follow up continued to December 2017. At baseline, 728 women (6.0%) reported historical IPV, 121 (1.0%) reported current violence, and 38 reported both (0.3%). Historical IPV increased 20-year mortality risk after controlling for demographic, socioeconomic, and lifestyle variables (hazard ratio 1.10, 95% confidence interval = [1.00, 1.20]). There was no relationship between current violence and mortality (hazard ratio 1.04, 95% confidence interval = [0.85, 1.29]). There was also no association between IPV and risk for incident dementia (hazard ratio 1.02, 95% confidence interval = [0.89, 1.17]). Older women who self-report exposure to IPV over the lifespan die significantly earlier than women who do not. Further research that considers the mediating role of psychological trauma is needed to examine the relationship between IPV and dementia.

Pregnancy complications are the major cause of maternal and newborn deaths in low- and middle-income countries that are more frequently associated with unintended pregnancy. The World Health Organization (WHO) recommends postnatal care (PNC) for women and their newborns within 24¿hr of birth to prevent pregnancy complications and associated adverse outcomes. We, therefore, examined the relationship between unintended pregnancy and PNC use in Bangladesh. Data from 4,493 women and newborn dyads were extracted from the 2014 Bangladesh Demographic and Health Survey and analysed. PNC was classified as: no PNC; some level of PNC (either the woman or her newborn missed PNC within 24¿hr of birth but had at least one PNC visit within 42¿days of birth); and WHO¿s recommended level of PNC (at least one PNC use for both the woman and her child within 24¿hr of birth). Pregnancy intention at conception for the last live birth was categorised as wanted, mistimed or unwanted. Multilevel multinomial logistic regression modelling was used to assess the association between pregnancy intention and PNC use, adjusting for possible confounders. We found around 27% of participants had adhered to WHO¿s PNC use recommendations. Around 26% of pregnancies that resulted in live births were unintended at conception, including 15% of which were classified as mistimed and 11% as unwanted. Following adjustment of confounders, a 37% (OR¿=¿0.63, 95% CI: 0.47¿0.85) lower odds of using WHO¿s recommended level of PNC and a 33% (OR, 95% CI, 0.49¿0.93) lower odds of some level of PNC were found for pregnancies that were unwanted relative to those that were wanted. No association was found between mistimed pregnancy and PNC use. Strengthening healthcare facilities and improving the linkage between women and existing healthcare facilities are important to ensure WHO¿s PNC recommendations are met for women experiencing an unwanted pregnancy.

Objective: To assess the psychological impacts and risk for elder abuse associated with historical intimate partner violence (IPV) in older women. Design: Prospective cohort study Setting: All Australian states and territories. Participants: A total of 12,259 women aged 70¿75 years at baseline participating in the Australian Longitudinal Study of Women's Health. Measurements: Women were asked at baseline whether they had ever been in a violent relationship with a partner, and completed a comprehensive survey about their physical and psychological health every 3 years (15 years follow-up) including the Short Form-36 Mental Health subscale (SF-MH) and Vulnerability to Abuse Screening Scale (VASS). Linear mixed effects modelling with maximum likelihood estimation assessed the impact of IPV over time on the SF-MH and VASS. Risk for incident depression and experiencing physical or sexual violence over follow-up was examined using logistic regression models. Results: The 782 (6.4%) women who reported historical IPV recorded significantly poorer psychological wellbeing at all timepoints compared to those who did not report historical IPV, and were at higher risk for incident depression over follow up (adjusted odds ratio [aOR] = 1.36, 95% confidence interval [CI]:1.11¿1.67). There was no significant relationship between historical IPV and self-reported exposure to physical or sexual violence in late life (aOR = 0.87, 95%CI: 0.53¿1.43), but women who reported historical IPV recorded higher rates of vulnerability to abuse on the VASS. Discussion: Women who have experienced a violent relationship continue to experience negative effects into older age, highlighting the importance of clinical monitoring and ongoing support for survivors as they age.

Background: Routine psychosocial assessment during pregnancy and the first postnatal year is a public health strategy that prioritises early identification of known risk factors for poor perinatal mental health. We aimed to report on the development and use of the Antenatal Risk Questionnaire-Revised (ANRQ-R), contribute normative data for a community sample of pregnant women and examine its test-retest reliability. Methods: The ANRQ-R was developed in consultation with an expert advisory group. Women completed the ANRQ-R with their midwife at their first antenatal appointment. Test-retest analysis was restricted to women who consented to follow-up and completed a repeat ANRQ-R within four weeks. Results: 7183 women completed the ANRQ-R (total score M = 12.05, Mdn=10; range =5¿49). There were some statistically significant differences in total score across maternal age group (¿2=69.75, p<.001), country of birth (¿2=144.01, p<.001) and socioeconomic quintiles (¿2=20.13, p<.001), however the effect sizes of all differences were either small or not clinically significant. Test-retest reliability for the ANRQ-R total score was good (N = 1670; ICC=0.77). Item-level test-retest reliabilities were moderate to good (ICC range=0.65¿0.80; kappa coefficient range=0.31¿0.74). Limitations: The study was conducted at a single site. Although there was significant diversity in terms of maternal age and country of birth, the majority of participants were partnered and resided in socio-economically advantaged areas, limiting the generalisability of results. Conclusions: This study contributes significant normative data for the ANRQ-R and offers valuable insights for clinicians and researchers working with particular sub-groups of the perinatal population. Additional psychometric examination of the ANRQ-R, including its concurrent and predictive validity, is required.

This study aimed to evaluate the association of the five-minute Apgar score and neurodevelopmental outcomes in children by taking the entire range of Apgar scores into account. Data from the Australian Longitudinal Study of Women¿s Health (ALSWH) and Mothers and their Children¿s Health (MatCH) study were linked with Australian state-based Perinatal Data Collections (PDCs) for 809 children aged 8-66 months old. Generalized estimating equations were used to model the association between the five-minute Apgar scores and neurodevelopmental outcomes, using STATA software V.15. Of the 809 children, 614 (75.3%) had a five-minute Apgar score of 9, and 130 (16.1%) had an Apgar score of 10. Approximately 1.9% and 6.2% had Apgar scores of 0-6 and 7-8, respectively. Sixty-nine (8.5%) of children had a neurodevelopmental delay. Children with an Apgar score of 0-6 (AOR = 5.7; 95% CI: 1.2, 27.8) and 7-8 (AOR = 4.1; 95% CI: 1.2, 14.1) had greater odds of gross-motor neurodevelopment delay compared to children with an Apgar score of 10. Further, when continuously modelled, the five-minute Apgar score was inversely associated with neurodevelopmental delay (AOR = 0.75; 95% CI: 0.60, 0.93). Five-minute Apgar score was independently and inversely associated with a neurodevelopmental delay, and the risks were higher even within an Apgar score of 7-8. Hence, the Apgar score may need to be taken into account when evaluating neurodevelopmental outcomes in children.

Objective Examine the relationship between preconception stress and offspring birth weight. Setting Population-based cohort study linked with state-based administrative perinatal data. Participants 6100 births from 3622 women from the 1973-1978 cohort of the Australian Longitudinal Study of Women's Health who (1) recorded a singleton birth between January 1997 and December 2011; (2) returned at least one follow-up survey within 3 years of conception; and (3) had complete data on perceived stress prior to conception. Primary outcome measures Linear generalised estimating equations were used to examine the relationship between preconception stress and a continuous measure of birth weight, exploring differences based on birth order and stress chronicity. The minimal sufficient adjustment set of covariates was determined by a directed acyclic graph. Results For all births, there was no relationship between moderate/high acute or chronic stress and offspring birth weight in grams. Among first births only, there was a trend towards a relationship between moderate/high chronic stress and offspring birth weight. Offspring sex was associated with birth weight in all models, with female babies born lighter than male babies on average, after adjusting for covariates (p<0.0001). Conclusions Effects of preconception stress on birth weight was largely driven by time to conception. With the timing of stress critical to its impact on obstetrical outcomes, preconception care should involve not only reproductive life planning but the space to provide interventions at critical periods so that optimal outcomes are achieved.

Objective: This study aimed to identify factors for different levels of anaemia among Ethiopian women and to estimate the population attributable fraction (PAF). Design: This study was a detailed analysis of data of the 2016 Ethiopian Demographic and Health Survey data. Adjusted OR (AOR) with 95 % CI was computed using multilevel multinomial regression models, and the PAF were estimated using these AOR. Setting: This study was conducted in Ethiopia. Participants: Women of reproductive age. Results: The PAF showed that the proportion of mild anaemia cases attributable to having no formal education was 14·6 % (95 % CI 3·4, 24·5), high gravidity (=4) was 11·2 % (95 % CI 1·2, 19·9) and currently breast-feeding was 5·2 % (95 % CI 0·0, 10·7). Similarly, the proportion of moderate-severe anaemia cases attributable to being in a rural residence was 38·1 % (95 % CI 15·9, 54·8); poorest wealth quantile, 12·6 % (95 % CI 2·9, 24·6); giving birth in the last 5 years, 10·5 % (95 % CI 2·9, 18·2) and unimproved latrine facilities, 17 % (95 % CI 0, 32·5). Conclusions: The PAF suggest that rural residency, low education, low wealth status, high parity, pregnancy and breast-feeding contribute substantially to the occurrence of anaemia among women in Ethiopia. Mild anaemia could be reduced by setting intervention strategies targeting women with low education, multigravida women and breast-feeding women, while preventing moderate-severe anaemia may require increasing income and improving living environments through the accessibility of hygienic latrines.

Background: Neonatal Near Miss (NNM) is a situation where a newborn narrowly survived the neonatal period. It has been hypothesized that identifying factors that contribute to the occurrence of NNM and taking timely interventions could enhance the quality of newborn care. However, there is limited evidence in Australia. This study aimed to identify the determinants of NNM in Australia. Methods: Data from the 1973¿78 cohort of the Australian Longitudinal Study on Women's Health (ALSWH) were linked with state-based Perinatal Data Collections (PDC) for 3655 mothers and 5526 newborns who were born between 01 January 2007 and 31 December 2015. A newborn was considered as a near miss case if presented with any of the pragmatic criteria (gestational age <32 weeks, birth weight <1500 g, five-minute Apgar score <7) and survived the neonatal period. A multilevel multivariable logistic regression model was used to identify the determinants of NNM. Results: Of the total 5526 live births included in this study, 95 live births met the criteria for NNM, corresponding to an incidence of 17.2 per 1000 live births. After controlling for potential confounders, maternal age 31¿34 years (AOR = 2.57; 95% CI: 1.05, 6.30) and 35 years and above (AOR = 4.03; 95% CI: 1.58, 10.31), caesarean section (AOR = 2.24; 95% CI: 1.09, 4.57), and gestational hypertension (AOR = 2.63; 95% CI: 1.21, 5.71) increased the odds of NNM. Conclusion: Inclusion of NNM evaluations into newborn care and early screening and interventions for women who become pregnant at older age and those with pregnancy complications could improve the quality of newborn care and reduce neonatal morbidity.

Background: Adverse childhood experiences have been linked to poor health and adverse health behavior in adulthood. Objective: This study aimed to estimate the prevalence of adverse childhood experiences among young Australian women (aged 20¿25) and examine associations between adverse childhood experiences and adult health behaviors and physical and mental health. Participants and Settings: Data were from the 1989-95 cohort of the Australian Longitudinal Study on Women's Health, who completed the Adverse Childhood Experiences Scale at Survey 3 in 2015 (N = 8609). Methods: Outcomes included: self-rated health, sexual health, psychological distress, depression, anxiety, suicide ideation, self-harm, substance abuse (drinking, smoking, illicit drugs), severe obesity, and exercise. Prevalence of childhood adversities were presented, with the association between childhood adversity and outcomes evaluated using log-binomial multivariable regressions (99% CI). Results: While 59% of women reported experiencing at least one childhood adversity, 10% of participants reported adverse childhood experiences across four or more categories, indicating a significant burden of risk for young Australian women. Women reporting four or more categories had higher rates of poor physical health (adjPR = 1.79, 99% CI = 1.51¿2.12), sexually transmitted infections (adjPR = 1.36, 99% CI = 1.11¿1.67), and poor mental health (adjPR = 2.78, 99% CI = 2.34¿3.32), and increased rates of severe obesity (adjPR = 2.14, 99% CI = 1.61¿2.86) and smoking (adjPR = 2.23, 99% CI = 1.89¿2.64). Conclusion: Using nationally representative data, this study shows adverse childhood experiences directly impact physical and mental health, and health behaviors in adulthood among young Australian women. The management of health and wellbeing in adulthood should look beyond the contemporaneous factors, incorporating a focus on how childhood adversity may negatively influence health behavior, health and wellbeing in later life.

Healthcare costs are lower for adults who consume more vegetables; however, the association between healthcare costs and fruit and vegetable varieties is unclear. Our aim was to investigate the association between (i) baseline fruit and vegetable (F&V) varieties, and (ii) changes in F&V varieties over time with 15-year healthcare costs in an Australian Longitudinal Study on Women¿s Health. The data for Survey 3 (n = 8833 women, aged 50¿55 years) and Survey 7 (n = 6955, aged 62¿67 years) of the 1946¿1951 cohort were used. The F&V variety was assessed using the Fruit and Vegetable Variety (FAVVA) index calculated from the Cancer Council of Victoria¿s Dietary Questionnaire for Epidemiological Studies food frequency questionnaire. The baseline FAVVA and change in FAVVA were analysed as continuous predictors of Medicare claims/costs by using multiple regression analyses. Healthy weight women made, on average, 4.3 (95% confidence interval (CI) 1.7¿6.8) fewer claims for every 10-point-higher FAVVA. Healthy weight women with higher fruit varieties incurred fewer charges; however, this was reversed for women overweight/obese. Across the sample, for every 10-point increase in FAVVA over time, women made 4.3 (95% CI 1.9¿6.8) fewer claims and incurred $309.1 (95% CI $129.3¿488.8) less in charges over 15 years. A higher F&V variety is associated with a small reduction in healthcare claims for healthy weight women only. An increasing F&V variety over time is associated with lower healthcare costs.

Background: The relationship between diet quality and health care costs is unclear. Objective: The aim of this study was to investigate the relationship between baseline diet quality and change in diet quality over time, with 15-year cumulative health care claims/costs. Design: Data from a longitudinal cohort study were analyzed. Participants/setting: Data for survey 3 (2001) (n = 7,868) and survey 7 (2013) (n = 6,349 both time points) from the 1946-1951 cohort of the Australian Longitudinal Study on Women's Health were analyzed. Main outcome measures: Diet quality was assessed using the Australian Recommended Food Score (ARFS). Fifteen-year cumulative Medicare Benefits Schedule (Australia's universal health care coverage) data were reported by baseline ARFS quintile and category of diet quality change (¿diet quality worsened¿ [ARFS change = ¿4 points], ¿remained stable¿ [¿3 = change in ARFS =3 points], or ¿improved¿ [ARFS change =4 points]). Statistical analyses: Linear regression analyses were conducted adjusting for area of residence, socioeconomic status, lifestyle factors, and private health insurance status. Results: Consuming a greater variety of vegetables at baseline but fewer fruit and dairy products was associated with lower health care costs. For every 1-point increment in the ARFS vegetable subscale, women made 3.3 (95% CI, 1.6-5.0) fewer claims and incurred AU$227 (95% CI, AU$104-350 [US$158; 95% CI, US$72-243]) less in costs. Women whose diet quality worsened over time made more claims (median, 251 claims; quintile 1, quintile 3 [Q1; Q3], 168; 368 claims) and incurred higher costs (AU$15,519; Q1; Q3, AU$9,226; AU$24,847 [US$10,793; Q1; Q3, US$6,417; US$17,281]) compared with those whose diet quality remained stable (median, 236 claims [Q1; Q3, 158; 346 claims], AU$14,515; Q1; Q3, AU$8,539; AU$23,378 [US$10,095; Q1; Q3, US$5,939; US$16,259]). Conclusions: Greater vegetable variety was associated with fewer health care claims and costs; however, this trend was not consistent across other subscales. Worsening diet quality over 12 years was linked with higher health care claims and costs.

CONTEXT: Ineffective use or nonuse of contraceptives following an unplanned birth can contribute to the risk of a subsequent unintended pregnancy; however, the literature on the relationship between unintended pregnancy and postpartum contraceptive use is sparse, especially in low-and middle-income countries. METHODS: Data on 4,493 women from the 2014 Bangladesh Demographic and Health Survey were analyzed; the subjects of the analysis had had a live birth in the three years prior to the survey and were currently at risk of pregnancy. Multilevel logistic regression analysis was used to examine associations between the intendedness of a woman¿s last pregnancy resulting in a live birth and her current modern contraceptive use adjusting for individual, household and community-level variables. RESULTS: Twenty-six percent of women reported that their last pregnancy resulting in a live birth had been unintended (15% mistimed and 11% unwanted); 61% reported current use of a modern contraceptive method. Compared with women who reported the pregnancy as having been wanted, those who reported the pregnancy as mistimed had greater odds of current modern contraceptive use (odds ratio, 1.6); no association was found between having had an unwanted pregnancy and subsequent modern contraceptive use. Other important correlates of modern contraceptive use included women¿s autonomy and desire for children, time since last birth and community-level poverty. CONCLUSIONS: Bangladeshi women who experience an unwanted pregnancy may have an elevated risk of subsequent unintended pregnancy. Broader coverage of family planning services, and integration of family planning with maternal health care, may increase modern contraceptive use following an unplanned birth.

In this article, we investigate differences in the profiles of patients within the Australian mixed public-private maternal health system to examine the extent of adverse selection. There are conflicting influences on adverse selection within the private health sector in Australia due to government regulations that incentivise lower risk segments of the population to purchase community-rated private health insurance. We use a two-phase modelling methodology that incorporates statistical learning and logistic regression on a dataset that links administrative and longitudinal survey data for a large cohort of women. We find that the key predictor of private patient status is having private health insurance, which itself is largely driven by sociodemographic factors rather than health-or pregnancy-related factors. Additionally, transitioning between the public-private systems for a subsequent pregnancy is uncommon; however, it is primarily driven by changes in private health insurance when it occurs. Other significant factors when transitioning to the private system for a second pregnancy are hypertension, increased access to specialists and stress related to previous motherhood experiences. Consequently, there is limited evidence of adverse selection in this market, with targeted financial incentives likely outweighing the impact of community rating even during childbearing years where private health service use increases.

Objectives: To describe the current contraception usage patterns from a cohort of Australian Indigenous women, including their ideal family size and spacing between children. Design: Cross-sectional analysis of data (2012-2019). Setting: Data are from a longitudinal study, the Gomeroi gaaynggal (babies from Gomeroi lands) program, based in rural and remote Gomeroi lands in New South Wales. Participants: Women carrying an Indigenous baby who enrolled during pregnancy were eligible for the study. The mother and child are then followed for up to 10¿years. Main outcome measures: Contraception usage in the postnatal period was recorded, as well as whether they were sexually active, whether they wanted more children and their preferred spacing between children. Medical, social and demographic information was also collected. These measures were self-reported via an online tool (Survey Monkey®) at their first visit to the study following the birth of their child. Results: Ninety-nine women were included in the analysis. Most women reported that they were sexually active at the time they were questioned about their contraceptive usage. The most popular contraception choices were condoms, the oral contraceptive pill and implant rods. Those answering that they did not want more children had a median of three children already. Those who wanted more children had a median of one child. The majority of the women stated that 2-3¿years between babies was ideal. Conclusion: The sampled women had clear beliefs about their ideal family size, in which contraceptive usage played an important part.

Skilled delivery care has been targeted in the Sustainable Development Goals to reduce preventable maternal and newborn deaths, which mostly occur because of birthing complications. Birthing complications are more frequent in women with unintended than intended pregnancies, and around 43% of total pregnancies in low-A nd middle-income countries are unintended. This study quantified the impact of unintended pregnancy on skilled birth attendance and delivery in health care facilities in Bangladesh. Data from 4493 women participating in the cross-sectional 2014 Bangladesh Demographic and Health Survey were analysed. Multilevel logistic regression models were used to assess the association of unintended pregnancy with skilled birth attendance and delivery in a health care facility through skilled providers while adjusting for individual-, household-A nd community-level factors identified using a directed acyclic graph. Around 26% of women reported that their last pregnancy (occurring within the previous 3 years) that ended with a live birth was unintended at conception. Only 42% reported having a skilled birth attendant present at their last birth and 38% gave birth in a health care facility. Significant differences were found across pregnancy intention. Lower odds of skilled birth attendance (OR, 0.70, 95% CI, 0.52-0.93) and delivery in a health care facility through skilled providers (OR, 0.65, 95% CI, 0.48-0.89) were found among women who had an unwanted pregnancy relative to women who had a wanted pregnancy. However, a mistimed pregnancy was not found to be associated with skilled birth attendance or delivery in health care facility through skilled providers. Increased availability of health care facilities at the community level is required in Bangladesh to ensure skilled delivery care for women with an unwanted pregnancy. Policies are also required to integrate women with an unwanted pregnancy into mainstream health care services through earlier detection and increased awareness in order to reduce the adverse maternal and fetal outcomes associated with lack of quality birthing care.

Objective: This study aimed to assess the effect of dietary patterns during pregnancy on HDP. A propensity score matched case-control study was conducted with 340 pregnant women (71 cases and 269 controls) in North Shewa Zone, Ethiopia. Data were collected through an interviewer-administered questionnaire and maternal anthropometry measurements. After propensity score matching, a conditional logistic regression model was used to identify the independent predictors of HDP by adjusting for the confounders. A p-value of < 0.05 was taken as statistically significant. Results: A high dietary diversity score (Adjusted Odd Ratio (AOR) = 0.45; 95% CI: 0.21, 0.93) was associated with a lower odds of HDP. Being merchant (AOR = 3.71 (95% CI: 1.16, 11.89), having previous history of HDP (AOR = 27.58; 95% CI: 4.53, 168.06) and high hemoglobin level (AOR = 2.26; 95% CI: 1.66, 3.09) were associated with an increased odds of HDP. Diet is an amendable factor, and the promotion of diversified diet is an important approach for preventing the occurrence of HDP. Women should be counselled to diversify their dietary intake to include a high amount of vegetables, legumes, and fruit.

Background: In Ethiopia, maternal health service utilization is still unacceptably low. The societal and cultural factors that constrain women from attending these services have not yet been sufficiently explored. Using qualitative methods, we aimed to explore the factors that delay maternal health service utilization in eastern Ethiopia. Method: A total of 13 audio-recorded focus group discussions were conducted comprising 88 participants. We conducted separate group discussions with reproductive aged women, mothers-in-law, traditional birth attendants, husbands, and Health Extension Workers to capture their knowledge, practices, feelings, thoughts and attitudes towards maternal health service utilization. The recorded sessions were transcribed into the local language and then translated into English for analysis. Result: The study identified a number of factors that may delay maternal health service utilization. Factors were grouped using the Three Delays model as a framework. Low level of awareness regarding need, poor involvement of husband, perceived absence of health problems, social power, community misperceptions and cultural restrictions, negative attitudes towards male midwives, acceptance of traditional birth attendants and poor social networking were Delay One factors. Lack of physical accessibility and high transportation costs were categorised as Delay Two factors for skilled birth care attendance. Perceived or experienced poor quality of care were categorised as Delay Three factors for both skilled birth and postnatal care utilization. Conclusion: Despite the ongoing government measures to improve maternal health service utilization in Ethiopia, numerous factors continue to contribute to delays in service use, which in turn contribute to high maternal mortality.

Background Current global maternal and child health policies rarely value gender equality or women's rights and are restricted to policies addressing clinical interventions and family planning. Gender equality influences the knowledge, autonomy and utilisation of contraception and healthcare, thereby affecting maternal and child health. This systematic review aims to analyse the concurrent effect of gender equality and contraception on maternal and under-5 child mortality. Methods A systematic review was conducted to investigate the current evidence. Studies were eligible if three themes -namely, indicators of gender equality (such as female education, labour force participation, gender-based violence), contraception, and maternal or child mortality -were present together in a single article analysing the same sample at the same time. Results Even though extensive literature on this topic exists, only three studies managed to fit the selection criteria. Findings of two studies indicated an association between intimate partner violence (IPV) and infant mortality, and also reported that women's contraceptive use increased the risk of IPV. The third study found that the mother's secondary education attainment significantly reduced child mortality, while the mother's working status increased the odds of child mortality. The researchers of all included studies specified that contraceptive use significantly reduced the risk of child mortality. Conclusion Improvement in gender equality and contraception concurrently affect the reduction in child mortality. These findings provide strong support to address the research gaps and to include a gender equality approach towards maternal and child health policies.

CONTEXT: Unintended pregnancy is common among young women. Understanding how such women use contraceptives¿ including method combinations¿is essential to providing high-quality contraceptive care. METHODS: Data were from a representative cohort of 2,965 Australian women aged 18¿23 who participated in the 2012¿2013 Contraceptive Use, Pregnancy Intention and Decisions baseline survey, had been heterosexually active in the previous six months, and were not pregnant or trying to conceive. Latent class analysis was employed to characterize women's contraceptive choices; multinomial logistic regression was used to evaluate correlates of membership in the identified classes. RESULTS: The vast majority of women (96%) reported using one or more contraceptives, most commonly short-acting hormonal methods (60%), barrier methods (38%), long-acting contraceptives (16%) and withdrawal (15%). In total, 32 combinations were reported. Four latent classes of method use were identified: no contraception (4% of women); short-acting hormonal methods with supplementation (59%, mostly the pill); high-efficacy contraceptives with supplementation (15%, all long-acting reversible contraceptive users); and low-efficacy contraceptive combinations (21%); supplementation usually involved barrier methods or withdrawal. Class membership differed according to women's characteristics; for example, women who had ever been pregnant were more likely than other women to be in the no-contraception, high-efficacy contraceptive or low-efficacy contraceptive combination classes than in the short-acting hormonal contraceptive class (odds ratios, 2.0-3.0). CONCLUSIONS: The complexity of women's contraceptive choices and the associations between latent classes and such characteristics as pregnancy history highlight the need for individualized approaches to pregnancy prevention and contraceptive care.

Objectives: To report rates of perinatal mental health screening from 2000 to 2017 and investigate factors associated with not being screened both antenatally and postnatally more recently (2013¿2017). Methods: A longitudinal community-based study of self-reported perinatal mental health screening with a national sample of 7,566 mothers from the Australian Longitudinal Study on Women's Health reporting on 9,384 children. The main outcome measure was whether mothers were asked about their emotional wellbeing by a health professional, including completing a questionnaire. Results: From 2000 to 2017, the percentage of women not screened decreased from 40.6% to 1.7%. The percentage of women screened both antenatally and postnatally increased from 21.3% to 79.3%. From 2013 to 2017, women who were older (aOR, 0.65; 95%CI, 0.52¿0.81) or had reported emotional distress (aOR, 0.77; 95%CI, 0.60¿0.99) were less likely to have been screened both antenatally and postnatally. Conclusions: Despite improvements, perinatal mental health screening is not yet universal. One-in-five women are not screened both antenatally and postnatally, including women in high-risk populations such as those who have reported emotional distress. Implications for public health: Women are in regular contact with health professionals in the perinatal period. This opportunity to detect women at risk of perinatal mental health issues is too important to be missed.

Background: Clinical practice guidelines recommend that women be screened for depression as a routine component of maternity care however there is ongoing debate about the benefits of depression screening programs in this context. Aim: This narrative review identifies and describes the clinical effectiveness of perinatal depression screening programs in relation to one or more of the following interrelated domains: referral for additional mental health support or treatment; engagement with mental health support or treatment options; and, maternal mental health or parenting outcomes. Methods: English-language studies, published up to July 2017, were identified and their methodological quality was assessed. RCTs and non-RCTs were included. Results: Overall, the majority of the fourteen studies identified showed that participation in a perinatal depression screening program increases referral rates and service use, and is associated with more optimal emotional health outcomes. One of four available studies demonstrated an improvement in parenting outcomes as a result of participation in an integrated postnatal depression screening program. Conclusion: This small but important body of work is integral to the continuing debate over the merits of screening for depression in the perinatal period. Current evidence favours the overall benefits of perinatal depression screening programs across the three focus areas of this review. Future research should consider a woman's broader psychosocial context and should address the economic as well as clinical outcomes of these programs. Rigorous evaluation of emerging digital approaches to perinatal depression screening is also required.

Background: For every neonate who dies, many others experience a near miss event that could have but did not result in death. Neonatal near miss is three to eight times more frequent than neonatal deaths and, therefore, is more useful for assessing the determinants of adverse neonatal outcomes. The aim of this study was to assess the incidence and determinants of neonatal near miss in south Ethiopia. Methods: A facility-based prospective study was conducted among 2704 neonates between 12 July to 26 November 2018. The neonates were followed from the time of admission to hospital discharge or seven postpartum days if the newborn stayed in the hospital. The data were collected by interviewer-administered questionnaire and medical record review. Logistic regression was employed to identify the distant, intermediate and proximal factors associated with neonatal near miss. The independent variables were analysed in three hierarchical blocks. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were used to determine the strength of the associations. Results: The incidences of neonatal near miss and neonatal death were 45.1 (95% CI = 37.7-53.8) and 17.4 (95% CI = 13.0-23.3) per 1000 live births, respectively. Of those newborns who experienced neonatal near miss, more than half (59.8%) of their mothers were referred from other health facilities. After adjusting for potential confounders, the odds of neonatal near miss were significantly higher among neonates with a low monthly income (< 79 USD monthly), a birth interval of less than 24 months and where severe maternal complications had occurred. Conclusion: Strategies to improve neonatal survival need a multifaceted approach that includes socio-economic and health-related factors. The findings of this study highlight important implications for policymakers with regard to neonatal near miss. In particular, addressing inequalities by increasing women's income, promoting an optimal birth interval of 24 months or above through postpartum family planning, and preventing maternal complications may improve newborn survival.

Objective: To cross-sectionally examine heavy episodic drinking (HED) and pre-loading with alcohol among young Australian women in relation to the alcohol-induced adverse outcomes of memory loss, vomiting and injury. Methods: A total of 7,800 participants, aged 20¿25 years, from the 1989¿95 cohort of the Australian Longitudinal Study on Women's Health answered all questions on alcohol use, reported drinking alcohol in the previous year and were not pregnant at the third survey in 2015. Log-binomial models were used to estimate prevalence ratios for adverse outcomes associated with increased frequency of HED and pre-loading. Results: The majority of participants reported HED (83.4%) and/or pre-loading (65.6%), which had a moderate correlation (r=0.646). Just over half (55.2%) of participants experienced at least one adverse event, with vomiting being most common. As the frequency of HED or pre-loading increased, so did the risk of an adverse outcome. Conclusions: Both HED and pre-loading pose a risk to young Australian women, and that risk rises with increased frequency. Implications for public health: Although HED has been a target of public health policy and interventions, pre-loading has received limited attention. In addition to addressing HED, there is a need to consider the risk posed by pre-loading, a related, yet unique risky drinking behaviour.

Gender-based violence (GBV) perpetration is a global public health problem due to its detrimental effect on health and education. This study aims to determine the prevalence of gender-based violence perpetration by male students in eastern Ethiopia. A cross-sectional study was conducted in eastern Ethiopia in December 2018. A total of 1064 male students were involved in the study. Data were collected using an adaptation of the WHO Multi-Country Study self-administered questionnaire on the Women Health and Life Event. Descriptive statistics were calculated using STATA version 14. The prevalence of gender-based violence committed by a male in the last 12 months was 55.83% (95% CI: 52.84¿58.82%). The prevalence of emotional abuse against an intimate or non-partner was 45.86% (95% CI: 42.87¿48.86%), physical abuse was 45.77% (95% CI: 42.77¿ 48.77%), and sexual abuse was 31.11% (95% CI: 28.32¿33.90%). The perpetration of multiple types of gender-based violence (emotional, physical, and sexual) was 47.15% (95% CI: 43.15¿51.25%), with 17.72% (95% CI: 14.75¿21.03%) reporting emotionally and physically violent acts, 14.21% (95% CI: 11.51¿17.27%) reporting emotionally violent acts only, and 12.88% (95% CI: 10.29¿15.82%) reporting physically violent acts only. There were statistically significant differences between the age of participants who committed acts of all forms of GBV in the ¿ever¿ timeframe and the past 12 months (p < 0.001). Effective prevention and intervention strategies should be developed at the school level to reduce gender-based violence perpetration.

Maternal depression is a potent risk factor for poor child development across a number of domains but the mechanisms of transmission are poorly understood. This study aimed to test competing mediators of the association between pre-conception maternal depression and child psychosocial functioning. In 2016, mothers in the 1973¿1978 cohort of the Australian Longitudinal Study on Women¿s Health were asked to be part of the Mothers and their Children¿s Health study and to complete surveys on the health of their three youngest children under 13¿years. The current study includes children aged 0¿12¿years (N = 5532, M = 6.99¿years, SD = 3.22¿years) and their mothers (N = 2917). We used the CESD-10 to measure depression and the PedsQL to measure psychosocial functioning, and used multilevel structural equation modeling to test hypotheses. Pre-conception maternal depression was associated with poorer maternal mental health and parenting after birth. The effect of pre-conception maternal depression was mediated by post-birth maternal depression in children aged 0¿4¿years (unstandardized regression coefficient (B) = - 0.26, 95%CI - 0.38, - 0.13) and children aged 5¿12¿years (B = - 0.25, 95%CI - 0.34, - 0.16), and by post-birth maternal stress (B = - 0.04, 95%CI - 0.08, - 0.01), and parenting (B = - 0.03, 95%CI - 0.04, - 0.02) in children aged 5¿12¿years. Post-birth maternal depression was the strongest mediator. Pre-conception is the optimal time for depression intervention. Post-birth interventions should include a focus on reducing depression and improving negative parenting aspects such as hostility and discipline.

Purpose: To evaluate the degree of honesty and level of comfort reported by women when questioned about their emotional wellbeing during the perinatal period; to investigate if honesty and comfort are associated with perinatal depression or perinatal anxiety; and to examine the reasons why women may not always respond honestly. Methods: Qualitative and quantitative data from 1597 women from the cross-sectional perinatal mental health substudy (part of the Australian Longitudinal Study on Women's Health) were analysed using a mixed methods approach. Results: When questioned by their health practitioner about their emotional wellbeing in the perinatal period, 20.7% of women indicated they had not always responded honestly. Reasons for not being honest reflected four main themes: normalizing of symptoms/coping; negative perceptions (self-and others); fear of adverse repercussions; and fear of involvement of health services (trust and confidentiality). The 38.9% of women who did not feel comfortable when questioned by their health practitioner about their emotional wellbeing were four times more likely to report perinatal depression (odds ratio = 4.09; 95% confidence interval = 2.55, 6.57) and nearly twice as likely to report perinatal anxiety (odds ratio = 1.90; 95% confidence interval = 1.24, 2.94) than other women. Conclusions: Women who are most likely to need mental health care during the perinatal period are also those least likely to be honest about their mental health. A non-judgemental, open and reassuring approach by clinicians may help to reduce the stigma and fears contributing to lack of honest responses, and improve early diagnosis and treatment of mental health problems.

This paper adopts an actuarial approach to identify the risk factors of government-funded maternal out-of-hospital costs in Australia, with a focus on women who experience adverse birth outcomes. We use a two-phase modelling methodology incorporating both classification and regression trees and generalised linear models on a data set that links administrative and longitudinal survey data from a large sample of women, to address maternal out-of-hospital costs. We find that adverse births are a statistically significant risk factor of out-of-hospital costs in both the delivery and postnatal periods. Furthermore, other significant cost risk factors are in-vitro fertilisation, specialist use, general practitioner use, area of residence and mental health factors (including anxiety, intense anxiety, postnatal depression and stress about own health) and the results vary by perinatal sub-period and the patient's private health insurance status. We highlight these differences and use the results as an evidence base to inform public policy. Mental health policy is identified as a priority area for further investigation due to the dominance of these factors in many of the fitted models.

Introduction Some studies in developing countries have shown that infant mortality is highly associated with maternal education, implying that maternal education might play an important role in the reduction of infant mortality. However, other research has shown that lower levels of maternal education does not have any significant contribution to infant survival. In this systematic review, we focus on the effect of different levels of maternal education on infant mortality in Ethiopia. Methods MEDLINE, EMBASE, CINAHL, Scopus, and Maternity and Infant Care databases were searched between November 15, 2017 and February 20, 2018. All articles published until February 20, 2018 were included in the study. The data extraction was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA 2009) guidelines. An I2 test was used to assess heterogeneity and a funnel plot was used to check publication bias. Findings We retrieved 441 records after removing duplications. During screening, 31 articles were fully accessed for data extraction. Finally, five articles were included for analysis. The overall pooled estimate indicated that attending primary education was associated with a 28% reduction in the odds of infant mortality compared to those infants born to mothers who were illiterate, OR: 0.72 (95% CI = 0.66, 0.78). Another pooled estimate indicated that attending secondary education and above was associated with a 45% reduction in the odds of infant mortality compared to those infants born to mothers who were illiterate, OR: 0.55 (95% CI = 0.47, 0.64).

Background Newborns are at greatest risk of dying at and shortly after the time of birth. Newborn mortality remains an urgent concern and is an important indicator of child health, development and well-being. Studies examining the effectiveness of antenatal care on maternal and newborn health outcomes have provided conflicting results. The aim of this review and meta-analysis was to determine the pooled effect of antenatal care on neonatal mortality in sub-Saharan Africa. Methods We searched PubMed, Medline, EMBASE, CINAHL and Google Scholar from September to November 2016 and then updated our search on April 13, 2019. Two independent reviewers extracted data from eligible studies. The quality of each included study was assessed using the Risk of Bias Assessment tool for Non-Randomized Studies (RoBANS). The results were reported based on risk ratio (RR) with 95% confidence intervals (CI) using a random-effects model. Results Eight hundred and ninety eight studies were initially identified. During screening, 23 studies were found to be relevant for data extraction. Of these, only twelve studies fulfilled the inclusion criteria and were included in the analysis. In five of the twelve studies included in the analysis, antenatal care service utilization had a significant association with neonatal mortality. The pooled risk ratio by the random-effects model was 0.61 (95% CI: 0.43, 0.86) for neonates born to women who received at least one antenatal care visit by a skilled provider as compared to neonates born to women who did not receive antenatal care. Conclusion This review indicates that utilization of at least one antenatal care visit by a skilled provider during pregnancy reduces the risk of neonatal mortality by 39% in sub-Saharan African countries. Thus, in order to accelerate progress towards the reduction of newborn deaths, all pregnant women should receive antenatal care during pregnancy.

The current study aims to present the prevalence of adverse childhood experiences and examine the healthcare costs associated with primary, allied, and specialist healthcare services. The Australian Longitudinal Study on Women¿s Health is a general health survey of four nationally representative age cohorts. The current study uses 20¿years of survey and administrative data (1996¿2015) from the cohort born 1973¿1978. Overall, 41% of women indicated at least one category of childhood adversity. The most commonly reported type of childhood adversity was having a household member with a mental illness (16%), with the most commonly reported ACES category being psychological abuse (17%). Women who had experienced adversity in childhood had higher healthcare costs than women who had not experienced adversity. The healthcare costs associated with experiences of adversity in childhood fully justify a comprehensive policy and practice review.

Introduction: E-cigarette use is controversial worldwide. The majority of previous studies on e-cigarette use were not gender specific. This study aimed to identify the predictors of e-cigarette use among young Australian women. Methods: This study used cross-sectional data from the 1989¿1995 cohort of the Australian Longitudinal Study on Women's Health. In 2015, study participants (N=8,915) aged 19¿26 years completed an online survey. Multivariable logistic regression was used to identify predictors of e-cigarette use. Data were analyzed in 2018. Results: The prevalence of ever and past-year e-cigarette use among young Australian women was 11.1% and 6.4%, respectively. More than a quarter of past-year and ever e-cigarette users were never cigarette smokers. Use of e-cigarettes in the past year was associated with younger age (AOR per year increase=0.87, 95% CI=0.82, 0.93); financial difficulty (AOR=0.68, 95% CI=0.54, 0.87); being an ex-smoker (AOR=5.05, 95% CI=3.64, 7.01) or current cigarette smoker (AOR=10.01, 95% CI=7.77, 12.89); drinking at a level of lifetime risk of harm from alcohol-related disease or injury (AOR=1.23, 95% CI=1.01, 1.53). Ever e-cigarette use showed similar associations and was also associated with rural residence (AOR=0.74, 95% CI=0.60, 0.91) and intimate partner violence (AOR=1.44, 95% CI=1.17, 1.76). Conclusions: The high prevalence of e-cigarette use among never cigarette smokers has significant public health implications. Interventions to curb the use of e-cigarettes among young Australian women should focus on risk factors, such as early age, cigarette smoking, alcohol use, and intimate partner violence.

In 2014, about 1.5 million pregnancies occurred among HIV-positive women in low and middle-income countries. To pool magnitude and factors associated with unintended pregnancy in women living with HIV in sub-Saharan Africa, a systematic search of electronic databases was undertaken in November 2016. Pooling the magnitude of unintended pregnancy reported by 14 studies yielded a crude summary prevalence of 55.9%. The magnitude of unwanted pregnancy and mistimed pregnancy in six studies ranged from 14 to 59 and 9 to 47.2%, respectively. Contraceptive failure was an important factor for many unintended pregnancies. The magnitude of unintended pregnancy was significantly higher in HIV-positive women than for HIV-negative women in three out of six studies. The available evidence suggests that there is a high magnitude of unintended pregnancy in this population. Improving effective contraceptive utilization is thus a priority to address unintended pregnancies and to prevent mother to child transmission of HIV. PROSPERO Number: CRD42016051310.

Objective: To evaluate the prevalence of eating disorders in women with polycystic ovary syndrome (PCOS) compared with women without PCOS and examine the relationship between PCOS, body mass index, self-esteem, and psychological distress scores. Design: Cross-sectional, community-based study. Setting: Not applicable. Patient(s): A total of 8,467 participants born between 1989 and 1995 in the Australian Longitudinal Study on Women's Health with self-reported PCOS status (PCOS n = 875 vs. non-PCOS n = 7,592). Intervention(s): None. Main Outcome Measures(s): Self-reported eating disorders, Rosenberg Self-Esteem Scale, and Kessler psychological distress scale. Result(s): Compared with women not reporting PCOS, women reporting PCOS had higher prevalence of eating disorders (11.0% vs. 7.6%), low self-esteem (31.7% vs. 24.2%), and psychological distress (severe psychological distress: 21.0% vs. 13.5%). After adjusting for confounders, women reporting PCOS were more likely to report eating disorders (adjusted odds ratio [OR] 1.6, 95% confidence interval [CI] 1.2¿2.0). Low self-esteem and psychological distress were highly correlated and further increased the odds of eating disorders in women reporting PCOS. Polycystic ovary syndrome was significantly associated with low self-esteem and psychological distress but not after adjusting for confounders. Obesity was associated with low self-esteem (adjusted OR 1.5, 95% CI 1.2¿1.8) and psychological distress (adjusted OR 1.2, 95% CI 1.0¿1.4) but not eating disorders. Underweight women had increased odds for eating disorders (adjusted OR 2.5, 95% CI 1.8¿3.4). Conclusion(s): Women with PCOS are more likely to report low self-esteem, psychological distress, and eating disorders. Low self-esteem and psychological distress are highly correlated and further increased the risk for eating disorders.

The perinatal period is a critical time for mental health and is also associated with high health care expenditure. Our previous work has identified a history of poor mental health as the strongest predictor of poor perinatal mental health. This study aims to examine the impact of a history of poor mental health on health care costs during the perinatal period. Data from the 1973¿1978 cohort of the Australian Longitudinal Study on Women¿s Health (ALSWH) were linked with a number of administrative datasets including the NSW Admitted Patient Data Collection and Perinatal Data Collection, the Medicare Benefits Scheme and the Pharmaceuticals Benefits Scheme between 2002 and 2011. Even when taking birth type and private health insurance status into account, a history of poor mental health resulted in an average increase of over 11% per birth across the perinatal period. These findings indicate that an investment in prevention and early treatment of poor mental health prior to child bearing may result in a cost saving in the perinatal period and a reduction of the incidence of women experiencing poor perinatal mental health.

Background: Postnatal care is critical to detect and manage postpartum complications in the early stages as well as to prevent potentially life-threatening health conditions that lead to maternal death. However, postnatal care utilization is persistently low in Ethiopia. The aim of this study is to assess the magnitude and correlates of postnatal care utilization among reproductiveaged women in Kersa district, in eastern Ethiopia. Methods: A community based cross-sectional study was conducted in ten randomly selected sub-districts in Kersa district. Respondents were recruited using systematic random sampling techniques. Data were collected by an interviewer-administered questionnaire using iPads. A total of 1206 respondents¿ data were considered in the analysis. Frequency and percentage distributions of the variables were performed. Bivariate and multivariate logistic regression analyses were undertaken to identify the predisposing, enabling and need factors associated with postnatal care utilization. An Odds Ratio with 95% confidence interval was used to ascertain the direction and strength of the association. Results: Less than one in thirteen women attended postnatal care after their last delivery in the study community. The multivariate analysis demonstrated that postnatal care utilization is associated with receiving education on maternal health, best friend's use of maternal care, head of the household, and experience of postpartum complications. Receiving education on maternal health (AOR, 2.32; 95% CI: 1.38, 3.89) and best friend's use of maternal care (AOR, 2.41; 95% CI: 1.39, 4.19) were significant predisposing factors that independently predicted postnatal care utilization. Furthermore, head of the household was a significantly associated enabling factor for postnatal care utilization (AOR, 0.24; 95% CI: 0.07, 0.81). The experience of postpartum complications (AOR, 0.10; 95% CI: 0.05, 0.20) was the only need factor that was associated with postnatal care utilization. Conclusion: Postnatal care utilization is extremely low in the study district. Strengthening health education and promotion activities on maternal health, peer education programs within the women's social networks, strengthening women empowerment programs, and women's mobilization to seek postnatal care before the occurrence of complications are essential actions that can improve postnatal care utilization.

Objective Epidemiological studies have indicated that dietary patterns during pregnancy are associated with adverse pregnancy and birth outcomes such as hypertensive disorders of pregnancy (HDP), gestational diabetes mellitus (GDM), preterm birth (PTB) and low birth weight (LBW). However, the results of these studies are varied and inconsistent. The present study aimed to assess the association between dietary patterns and the risk of adverse pregnancy and birth outcomes.Design Systematic review and meta-analysis. Seven databases were searched for articles. Two reviewers performed the study selection and data extraction. A random-effects model was used to estimate pooled effect sizes of eligible studies.Setting Studies conducted all over the world were incorporated.Subjects The review focused on pregnant women.Results A total of twenty-one studies were identified. Adherence to a healthy dietary pattern (intake of vegetables, fruits, legumes, whole grains) was significantly associated with lower odds (OR; 95 % CI) of pre-eclampsia (0·78; 0·70, 0·86; I 2=39·0 %, P=0·178), GDM (0·78; 0·56, 0·99; I 2=68·6 %, P=0·013) and PTB (0·75; 0·57, 0·93; I 2=89·6 %, P=0·0001).Conclusions Our review suggests that dietary patterns with a higher intake of fruits, vegetables, legumes, whole grains and fish are associated with a decreased likelihood of adverse pregnancy and birth outcomes. Further research should be conducted in low-income countries to understand the impact of limited resources on dietary intake and adverse pregnancy and birth outcomes.

Objectives: We examined the development of disease and disability in a large cohort of older women, the extent to which these conditions exempt them from being classified as successful agers and different trajectories of disease, disability and longevity across women's later life. Methods: We used survey data from 12,432 participants of the 1921-26 birth cohort of the Australian Longitudinal Study of Women's Health from 1996 (age 70-75) to 2016 (age 90-95). Repeated measures latent class analysis (RMLCA) identified trajectories of the development of disease with or without disability and according to longevity. Bivariate analyses and multivariable multinomial logistic regression models were used to examine the association between participants' baseline characteristics and membership of the latent classes. Results: Over one-third of women could be considered to be successful agers when in their early 70s, few women could still be classified in this category throughout their later life or by the end of the study when they were in their 90s (~1%). RMLCA identified six trajectory groups including managed agers long survivors (9.0%) with disease but little disability, usual agers long survivors (14.9%) with disease and disability, usual agers (26.6%) and early mortality (25.7%). A small group of women having no major disease or disability well into their 80s were identified as successful agers (5.5%). A final group, missing surveys (18.3%), had a high rate of non-death attrition. Groups were differentiated by a number of social and health factors including marital status, education, smoking, body mass index, exercise and social support. Conclusions: The study shows different trajectories of disease and disability in a cohort of ageing women, over time and through to very old ages. While some women continue into very old age with no disease or disability, many more women live long with disease but little disability, remaining independent beyond their capacity to be classified as successful agers.

Background Polycystic ovary syndrome (PCOS) is associated with increased psychological distress in clinical populations. We aimed to assess depression, anxiety and perceived stress in women with and without PCOS in a large community-based sample and investigate the role of stress in contributing to and mediating the relationship between PCOS, depression and anxiety.Methods A cross-sectional analysis was performed from the Australian Longitudinal Study of Women's Health (ALWSH) comparing women with (n = 478) or without (n = 8134) a self-reported diagnosis of PCOS. Main outcome measures were depression, anxiety and perceived stress measured using validated scales. The ¿2 and t tests were used to assess differences between groups. Univariable and multivariable regression were performed to determine factors contributing to each outcome.Results Women reporting PCOS, compared with women not reporting PCOS, reported higher prevalence of depression (27.3% v. 18.8%), anxiety symptoms (50% v. 39.2%) and greater score for perceived stress (1.01 ± 0.03 v. 0.88 ± 0.01). After adjusting for body mass index, infertility and socio-demographic factors, women with PCOS were still more likely to be depressed, anxious and to have a higher level of perceived stress. There was a high-level mediation effect of stress between PCOS and both depression and anxiety.Conclusion Compared with women not reporting PCOS, women reporting PCOS have increased depression, anxiety and perceived stress. Stress may play a role in the association between PCOS, depression and anxiety. Further studies should consider assessment and management of stress in PCOS as it may be relevant for understanding the aetiology and treatment of psychological distress.

Objectives: To examine the association between unintended pregnancy and maternal healthcare services utilization in low- and lower-middle-income countries. Methods: A systematic literature search of Medline, Cinahl, Embase, PsycINFO, Cochrane Library, Popline, Maternity and Infant Care, and Scopus databases published since the beginning of the Millennium Development Goals (i.e. January 2000) to June 2018 was performed. We estimated the pooled odds ratios using random effect models and performed subgroup analysis by participants and study characteristics. Results: A total of 38 studies were included in the meta-analysis. Our study found the occurrence of unintended pregnancy was associated with a 25¿39% reduction in the use of antenatal, delivery, and postnatal healthcare services. Stratified analysis found the differences of healthcare services utilization across types of pregnancy unintendedness (e.g. mistimed, unwanted). Conclusions: Integrating family planning and maternal healthcare services should be considered to encourage women with unintended pregnancies to access maternal healthcare services.

Objective: To develop a greater understanding of the motivators of contraceptive method change over time for young Australian women, with a particular interest in long-acting reversible contraception (LARC) use. Method: Free-text comments from the Contraceptive Use, Pregnancy Intention and Decisions (CUPID) Study were used to explore the reasons for contraceptive method change among women who reported one or more contraceptive changes across the three CUPID surveys. Results: 512 women reported making at least one contraceptive method change, with 740 comments explaining these changes between them. Participants reported a multitude of reasons motivating their contraceptive change. Five key themes were developed to explain these motivators: the natural, sexual and fertile body, specific contraceptive characteristics and other important people. Findings suggest that women's decisions to switch or discontinue a contraceptive depended largely on her ability (and desire) to juggle its impact on her sexual, fertile and natural body. Importantly, the transient and fluid nature of contraceptive practices were demonstrated, as the women adjusted their method to suit their needs at the time. Conclusion: Regarding LARC use, these findings suggest that rather than being appealing, the ¿temporarily permanent¿ nature of these methods may be unappealing and incongruent with the needs of some women.

Background Although it is known that pregnancy intention impacts contraceptive use, there has been little exploration into the relationship between pregnancy intention and long-acting reversible contraception (LARC) non-use in the Australian context. Methods Semi-structured telephone interviews with a sample of participants from the Contraceptive Use, Pregnancy Intention and Decisions (CUPID) Study were conducted in 2016. Results Of the 59 women contacted, 15 participated in an interview. One theme arising from these interviews is reported here. Results from the analysis suggest that women with ambivalent or unclear plans toward pregnancy were less likely to perceive LARC as a suitable method for them. Conversely, women who clearly intended to avoid pregnancy and who had clear plans for future pregnancy valued these methods, and often framed their future plans for pregnancy within the context of their chosen LARC. Conclusions Findings presented demonstrated the complex relationship between pregnancy intention and contraceptive use. In particular, this study provided insight into the complex notion of pregnancy ambivalence. Dichotomous definitions of pregnancy as intended or unintended were found to be inadequate in encapsulating actual reproductive experiences.

We investigate an actuarial approach to identifying the factors impacting government-funded maternal hospital costs in Australia, with a focus on women who experience adverse birth outcomes. We propose a two-phase modelling methodology that adopts actuarial methods from typical insurance claim cost modelling and extends to other statistical techniques to account for the large volume of covariates available for modelling. Specifically, Classification and Regression Trees and generalised linear mixed models are employed to analyse a data set that links longitudinal survey and administrative data from a large sample of women. The results show that adverse births are a statistically significant risk factor affecting maternal hospital costs in the antenatal and delivery periods. Other significant cost risk factors in the delivery period include mode of delivery, private health insurance status, diabetes, smoking status, area of residence and onset of labour. We demonstrate the efficacy of using actuarial techniques in non-traditional areas and highlight how the results can be used to inform public policy.

Scant research exists on the patterns of changes in older women¿s housing, and whether and when women transition into residential aged care (RAC). This study aimed to identify groups of women with different housing patterns (latent classes) over time, with a secondary aim to describe socio-demographic and health characteristics of women in each class. We analysed linked data for 9575 women born 1921¿1926 from the Australian Longitudinal Study of Women¿s Health (ALSWH), Australian National Death Index, and Residential Aged Care (RAC) administrative records for the years 1999 through to 2011. Seven distinct housing patterns (classes) were identified over time. Four classes showed a stable pattern: living in a house for most surveys (47.0%), living in a house but with earlier death (13.7%), living in an apartment (12.8%), living in a retirement village (5.8%). One class showed a pattern of downsizing: moving from a house to retirement village (6.6%). Two patterns showed transition: from an apartment or retirement village, to RAC and death (7.8%), and from house to RAC (6.4%). This study provides new evidence about socio-demographic and health influences on housing patterns and entry into residential care in later life. These findings can inform policy and aged care planning for women in later life, by identifying patterns of transition into residential aged care, or alternatively, remaining in the community.

Purpose: Postural Orthostatic Tachycardia Syndrome is most commonly seen in women of child bearing age, however little is known about its effects in pregnancy. Method: A systematic review was conducted in March 2015 and updated in February 2018. Medline, Embase, PsychInfo, CINHAL, and the Cochrane Library were searched from database inception. The ClinicalTrials.gov site and bibliographies were searched. MeSH and Emtree headings and keywords included; Postural Orthostatic Tachycardia Syndrome, Postural Tachycardia Syndrome, and were combined with pregnancy and pregnancy related subject headings and keywords. Searches were limited to English. Eligible articles contained key words within the title and or abstract. Articles were excluded if Postural Orthostatic Tachycardia Syndrome was not pre-existing. Results: Eleven articles were identified as eligible for inclusion. Studies were appraised using the PRISMA 2009 guidelines. The overall quality of evidence was poor using the NHMRC Evidence Grading Matrix, which was attributed to small sample sizes and mostly observational studies, emphasizing the need for future high quality research. Findings in this review must be used with caution due to the poor quality of the literature available. Conclusions: Postural Orthostatic Tachycardia Syndrome should not be a contraindication to pregnancy. Symptom course is variable during pregnancy and the post-partum period. Continuing pre-conception medication may help symptoms, with no significant risks reported. Obstetric complications, not Postural Orthostatic Tachycardia Syndrome, should dictate mode of delivery. Postural Orthostatic Tachycardia Syndrome did not appear to affect the rate of adverse events. These results are important in determining appropriate management and care in this population.

Background: Preventable maternal mortality is related to delays in recognizing the problem, transport to a facility, and receiving appropriate care on arrival. Reducing maternal mortality in low-literacy settings is particularly challenging. In the rural villages of Nepal, the maternal mortality rate is among the highest in the world; the reasons include illiteracy and lack of knowledge of the needs of pregnant women. Culturally, singing and dancing are part of Nepalese daily life and present an opportunity to transmit knowledge of antenatal care and care at birth with a view to reducing the first 2 delays. Objective: We hypothesized that health messages regarding the importance of antenatal care and skilled birth assistance would be effectively transmitted by songs in the limited literacy environment of rural Nepal. Study Design: We randomly grouped 4 rural village development committees comprising 36 villages into 2 (intervention and control) clusters. In the intervention group, local groups were invited to write song lyrics incorporating key health messages regarding antenatal care to accompany popular melodies. The groups presented their songs and dances in a festival organized and judged by the community. The winning songs were performed by the local people in a song and dance progression through the villages, houses, and fields. A wall chart with the key health messages was also provided to each household. Knowledge of household decision makers (senior men and women) was assessed before and after the intervention and at 12 months using a structured questionnaire in all households that also assessed behavior change. Results: Structured interviews were conducted at baseline, immediately postintervention in the control and intervention areas (intervention n = 735 interviews, control n = 775), and at 12 months in the intervention area only (n = 867). Knowledge scores were recorded as the number of correct items out of 36 questions at baseline and postintervention, and of 21 questions at follow-up. Postintervention, test score doubled in the intervention group from a mean of 11.60/36¿22.33/36 (P <.001), with no practically significant change in the control population (17.48/36¿18.26/36). Improvement was greatest among the most illiterate members of the community (6.8/36¿19.8/36, P <.001). At 12 months follow-up, a majority of the participants (63.9%) indicated that they provided information learned from the songs to their neighbors and friends, and 41.3% reported still singing the songs from the intervention. Conclusion: The use of songs bypassed the limitations of literacy in communicating health messages that are key to improving maternal care in this low-literacy rural setting within a developing country. The improvements were maintained without further intervention for 12 months. With appropriate sociocultural adaptation to local contexts, this low-cost method of community education may be applicable to improving maternal health knowledge and behavior change in other low-resource and limited literacy settings that may lead to reductions in maternal mortality.

Objective: To provide a direct estimate of the risk of admission to permanent residential aged care among older women while accounting for death, according to housing type and other variables. Methods: A competing risk analysis from 8,867 Australian women born 1921¿26, using linked data from the Australian Longitudinal Study on Women's Health (ALSWH), Residential Aged Care (RAC), and the Australian National Death Index. Results: After accounting for deaths, around 35% of women will be admitted to RAC between ages 73 and 90. The conditional cumulative incidence of admission to RAC was 26.9% if living in a house, compared to 36.0% from an apartment, 43.6% within a retirement village, and 37.1% if living in a mobile home. Each one-year increase in age was associated with a relative 17% increased risk of RAC. Conclusions: Around one-third of women will enter RAC between age 73 and 90. Living in a house had the lowest risk of entering residential aged care over time. Implications for public health: These findings have important implications for planning for aged care services, including the role of housing in delaying admission to residential aged care, and the need for residential care by a high proportion of women towards the end of life.

This study examined factors associated with use of government subsidised mental health services by 229,628 men and women from the Sax Institute¿s 45 and Up Study. Logistical regression models assessed use of mental health services by gender and according to level of psychological distress. Approximately equal proportion of men and women had high psychological distress scores (approximately 7%) but only 7% of these men and 11% of these women used services. Use was associated with predisposing (younger age and higher education), enabling (private health insurance) and need factors (higher psychological distress scores). Associations were similar for men and women except urban area of residence, separated/divorced marital status, and smoking were associated with service use for women but not men. Results suggest some inequity in the use of services by those with higher levels of need and further efforts may be required to reach people with higher need but lower service use.

Objective To determine rates of vaginal delivery, emergency caesarean section, and elective caesarean section for first and second births in Australia, and to identify maternal predictors of caesarean section. Methods Data were from the Australian Longitudinal Study on Women¿s Health. A total of 5275 women aged 18¿38 years, who had given birth to their first child between 1996 and 2012 were included; 75.0% (n = 3956) had delivered a second child. Mode of delivery for first and second singleton birth(s) was obtained from longitudinal survey data. Socio-demographic, lifestyle, anthropometric and medical history variables were tested as predictors of mode of delivery for first and second births using multinomial logistic regression. Results Caesarean sections accounted for 29.1% (n = 1535) of first births, consisting of 18.2% emergency and 10.9% elective caesareans. Mode of delivery for first and second births was consistent for 85.5% of women (n = 3383) who delivered both children either vaginally or via caesarean section. Higher maternal age and body mass index, short-stature, anxiety and having private health insurance were predictive of caesarean section for first births. Vaginal birth after caesarean section was more common in women who were older, short-statured, or had been overweight or obese for both children, compared to women who had two vaginal deliveries. Conclusions for Practice Rates of caesarean section in Australia are high. Renewed efforts are needed to reduce the number of unnecessary caesarean births, with particular caution applied to first births. Interventions could focus on elective caesareans for women with private health insurance or a history of anxiety.

Aims and objectives: To explore in detail how women perceived their experience of domestic violence and leaving or ending the abuse. This research also examined how service providers identified their professional role in assisting women to end such relationships. Background: Domestic violence against women continues to occur internationally. Reliable statistics are difficult to capture because of inconsistent definitions, contradictory methods of acquiring data and unreported incidents. Design: A qualitative study, undertaken in two phases, was conducted in Australia. Methods: Twelve women who had experienced domestic violence and ended those relationships participated in one semistructured interview (Phase 1). Twenty-five professionals from health, social sciences and law, whose work included assisting women experiencing domestic violence, participated in three focus groups (Phase 2). Thematic analysis guided by a narrative inquiry approach forms the framework for information collection and interpretation of data in this project. Findings: The barriers that impede women from disclosing abuse and taking action to end domestic violence are complex and varied between participants. Women did not always acknowledge or realise their relationship was precarious and often denied or minimised the abuse to cope with the domestic violence. Professionals identified that women did not always identify or acknowledge abuse inherent in their relationship although this delayed the provision of appropriate services. Conclusion: Whether women disclose abuse or deny violence in their relationship, acceptance by service providers and the offer of support is crucial to assisting women in violent relationships. Relevance to clinical practice: It is hoped that the findings may assist health practitioners, including nurses, to provide nonjudgemental support to women experiencing domestic violence whether women acknowledge the abusive relationship or not.

Objective To explore the characteristics of long-acting reversible contraception (LARC) users in a nationally representative cohort of young Australian women aged 18¿23. Methods Data from 3155 women who responded to a question about their contraceptive use in the previous six months at the baseline Contraceptive Use, Pregnancy Intention and Decisions (CUPID) survey were included. Results 726 (19.1%) women reported LARC use, with the Implanon being the most popular method (n¿=¿478; 65.8%). A history of pregnancy was strongly associated with increased odds of LARC use in the multivariate model (OR¿=¿2.67, 95% CI¿=¿2.11, 3.34, p¿=¿0.001). Comparatively, using contraception for reasons other than pregnancy prevention was associated with decreased odds of LARC use in the multivariate model (period management: OR¿=¿0.74, 95% CI¿=¿0.60, 0.91, p¿=¿0.004, body management: OR¿=¿0.53, 95% CI¿=¿0.37, 0.77, p¿=¿0.001, medical condition: OR¿=¿0.25, 95% CI¿=¿0.09, 0.66, p¿=¿0.005). Highest education and Medicare card status also contributed to the final multivariate model, and were associated with decreased odds of LARC use. Conclusion Reproductive history and reasons for contraceptive use are strong indications of method choice. Promoting LARC as highly effective may not be a sufficient incentive for young women to take up the method when pregnancy prevention may be equal or secondary to their desired non-contraceptive effects.

Objective: To identify the prevalence of bullying among women aged 18¿23 in 2013, and to describe the demographic characteristics, health and risk factors of those who experienced bullying. Methods: Cross-sectional analysis using data from the 1989¿95 cohort of the Australian Longitudinal Study on Women's Health, a nationally representative cohort (n=16,801). Results: More than one-quarter of women (28.4%) indicated they had never been bullied, 53.4% reported experiencing bullying in the past and 18.2% indicated that they were recently bullied. Women who had experienced bullying were more likely to have lower levels of education, less likely to be studying or employed, and had more difficulty managing on their income. Women who experienced bullying were more likely to use tobacco or illicit drugs, be overweight or obese and to be sedentary. Even after adjusting for these factors, women who had experienced bullying were at risk of poor physical health, psychological distress, suicidal thoughts and self-harm. Conclusions: This is the first nationally representative study to demonstrate the strong association between being a victim of bullying and health outcomes in a post-school-age population. Implications for public health: The findings highlight the need for interventions for women who have already experienced bullying and are past school age.

Introduction. Polycystic ovary syndrome (PCOS) affects 9-21% of reproductive- age women. The relations between PCOS, body mass index (BMI) and breastfeeding are unclear. Our aim was to examine breastfeeding in women with and without PCOS and the relation with BMI. Material and methods. This is a cross-sectional study set in the general community. Participants are women, aged 31-36 years, from the Australian Longitudinal Study on Women's Health (ALSWH), a large community-based study. Data was analyzed from the first child of respondents to Survey five (2009) reporting at least one live born child. Logistic regression analysis was used to examine factors associated with breastfeeding. The main outcome measures studied were breastfeeding initiation and duration and the main explanatory variables included selfreported PCOS and BMI. Results. Of the 4898 women, 6.5% reported PCOS (95% confidence interval 5.8-7.2%). Median duration of breastfeeding was lower in women reporting PCOS (6 months, range 2-10 months) than in women not reporting PCOS (7 months, range 3-12 months) (p = 0.001). On multivariable regression analysis, there was no association between PCOS and breastfeeding outcomes. However, being overweight or obese was associated with not initiating breastfeeding and with breastfeeding for less than 6 months, after adjusting for confounders. Conclusions. High BMI is negatively associated with breastfeeding, whereas PCOS status per se does not appear to be related to breastfeeding initiation and duration, after adjusting for BMI.

Data from a national, population-based longitudinal study of Australian women (26-34 years) were analyzed to investigate the association between domestic relocation and multiple explanatory factors, namely intimate partner violence (IPV), metropolitan versus non-metropolitan residence, education, income, housing tenure, number of children, and changes in relationship status. Experience of IPV in the past 12 months was significantly associated with increased odds of domestic relocation. This association remained significant after controlling for age, social support, area of residence, income, number of children, education, and housing situation. Change in relationship status attenuated the association between recent IPV and domestic relocation. Metropolitan versus non-metropolitan residence had no major influence on these results.

New developments in female contraceptives allow women increased options for preventing pregnancy, while men¿s options for reversible contraception have not advanced beyond the condom. There has been little discursive exploration of how neoliberal and postfeminist discourses shape women¿s accounts of choosing whether or not to use contraception. Our thematic discourse analysis of 760 free-text responses to a question about contraceptive choice considers the social and political climate that promotes the self-governed woman who freely chooses contraception. We examine the ways in which women formulated and defended their accounts of choice, focusing on the theme of free contraceptive choice that constructed women¿s choices as unconstrained by material, social and political forces. We identify two discursive strategies that underpinned this theme: a woman¿s body, a woman¿s choice and planning parenthood, and explore the ways in which choice was understood as a gendered entitlement and how contraceptive choices were shaped (and constrained) by women¿s plans for parenthood. We discuss the implications of these discursive strategies, and neoliberal and postfeminist discourses, in terms of the disallowance of any contextual, social and structural factors, including the absence of men in the ¿contraceptive economy¿.

Background: The long-term impact of binge drinking on subsequent depressive symptoms is unclear. The aims were to identify longitudinal patterns of binge drinking and whether binge drinking preceded depressive symptoms in the short-term (1-6 years) and long-term (10-15 years). Methods: Longitudinal data from 1996, 2000 and 2009 mailed surveys of 8,197 women in the 1973-78 cohort of the Australian Longitudinal Study on Women's Health. Latent class analysis was used to identify binge drinking patterns and logistic regression to estimate associations with subsequent depressive symptoms. Results: Five binge drinking trajectories were identified with predicted proportions of women who were very infrequent (24%), fluctuating infrequent (17%), frequent (17%), very frequent (26%) or extremely frequent binge drinkers (16%) between 16 and 21 years. At 22-27 years, depressive symptoms were significantly higher for extremely frequent binge drinkers (31% versus 21% in the short-term; 22% versus 16%-18% in the long-term) than for less frequent bingers. Unadjusted odds of depressive symptoms were 1.70 (95%CI:1.38;2.08) times for extremely frequent binge drinkers than very infrequent bingers and were 1.30 (95%CI:1.04;1.63) after adjusting for demographics, relationships and experience of violence. At 31-36 years, the odds of depressive symptoms were 1.34 (95%CI:1.09-1.64) times for extremely frequent than very infrequent binge drinkers, but were not significant after adjusting for relationships and violence. Conclusions: Extremely frequent binge drinking (more than weekly) in late adolescence appears to elevate the risk of subsequent depressive symptoms in young women in their early twenties and thirties, emphasising the need for preventive strategies to curb binge drinking.

Purpose While previous studies have identified a range of potential risk factors for postnatal depression (PND), none have examined a comprehensive set of risk factors at a population-level using data collected prospectively. The aim of this study was to explore the relationship between a range of factors and PND and to construct a model of the predictors of PND. Methods Data came from 5219 women who completed Survey 5 of the Australian Longitudinal Study on Women's Health in 2009 and reported giving birth to a child. Results Over 15% of women reported experiencing PND with at least one of their children. The strongest positive associations were for postnatal anxiety (OR = 13.79,95%CI = 10.48,18.13) and antenatal depression (OR = 9.23,95%CI = 6.10,13.97). Positive associations were also found for history of depression and PND, low SF-36 Mental Health Index, emotional distress during labour, and breastfeeding for less than six months. Conclusions Results indicate that understanding a woman's mental health history plays an important role in the detection of those who are most vulnerable to PND. Treatment and management of depression and anxiety earlier in life and during pregnancy may have a positive impact on the incidence of PND.

Little research examining qualities of contraception that make them attractive or unattractive to users, particularly young women, exists. The aim of this study is to systemically review the evidence regarding desirable and undesirable qualities of long-acting reversible contraception (LARC), including intrauterine devices, the implant and the injection, as perceived by women. Five electronic databases were searched in May 2015 using terms related to LARC and method preference or decision-making. Studies were included if they concerned women aged 18-23 years from developed countries and reported on perceived positive or negative qualities of LARC. Thirty articles were deemed relevant. Five key themes emerged under which qualities were categorised; including: (1) impact on bleeding; (2) impact on the body; (3) device-specific characteristics; (4) general characteristics; and (5) perceptions and misbeliefs. Fit and forget, high efficacy and long-term protection were considered the top desirable qualities of LARC. Undesirable qualities varied among the LARC methods; however, irregular bleeding, painful insertion and removal procedure, weight gain and location in the body were among those most commonly reported. The contraceptive benefits of LARC, including their high efficacy and longevity, are generally considered to be positive qualities by women, while the potential impact of side-effects on the body are considered as negative qualities. This information is crucial in the clinical setting as it provides practitioners with a greater understanding of the qualities women do and do not like about LARC methods. Discussion about these qualities, positive and negative, during consultations about contraception may increase rates of uptake.

Background: Because childhood sexual abuse (CSA) and adult violence are associated with poorer physical and mental health of women, our aim was to investigate the associations between CSA, adult violence experiences and general practice service use and satisfaction in a community sample of Australian women aged 28-33 years. Methods: Data of 9058 women from the 1973-78 cohort who completed Survey 4 of the Australian Longitudinal Study on Women's Health were analysed. Results: Logistic regressions conducted indicated that after controlling for demographic variables, women with experiences of lifetime violence were more likely to have higher general practice service use compared to those without violence experiences. CSA was not associated with an increase in service use but was significantly associated with a decrease in service satisfaction. This finding remained significant even when they visited the general practice more frequently. Discussion: Implementing trauma-informed care is suggested as a way to improve the satisfaction of this patient group with complex needs.

Objectives: To examine bias arising from loss to follow-up due to lack of contact. Study Design and Setting: The 1973-1978 cohort of Australian Longitudinal Study on Women's Health was first surveyed in 1996 and followed up in 2000, 2003, 2006, and 2009. At the 2000 survey, 9,688 women responded (responders), 2,972 could not be contacted, of whom 1,515 responded subsequently (temporary no contact) and 1,457 did not (permanent no contact). Characteristics were compared for these groups at baseline and follow-up in 2003, 2006, or 2009. Relative risk ratios were used to estimate bias. Results: No-contacts were younger, more likely to live in cities, to be less educated and stressed about money than responders. No-contacts were more likely to be in de facto relationships, separated, divorced, or widowed, to have experienced partner violence and be smokers. Compared with temporary no contact, permanent no contact were less educated, less likely to be studying or employed. Despite differences in prevalence estimates, relative odds ratios were close to one and had confidence intervals that included one, indicating little effect of bias. Conclusion: Although various characteristics were related to loss to follow-up, the relative risks estimates did not indicate serious bias due to loss to follow-up in this cohort of young women.

Introduction and Aims: To examine women's drinking behaviour relative to Australian guidelines and identify associated factors over the lifespan. Design and Methods: Data came from three prospective cohorts of the Australian Longitudinal Study on Women's Health aged 18-23 (n=14247), 45-50 (n=13715) and 70-75 years (n=12432) when first surveyed in 1996. The same women were re-surveyed at roughly 3-year intervals until 2012. At each survey, four drinking behaviours were based on two guidelines: long-term drinking (no more than two standard drinks per day) and episodic drinking (no more than four standard drinks on an occasion): (i) no risk (within both guidelines); (ii) low episodic risk (less than once a month); high episodic risk (at least once a month); long-term risk (more than two drinks per day regardless of episodic drinking). Results: No risk drinking increased with age, low episodic risk drinking remained almost constant between ages 18 and 39, and high episodic risk drinking declined rapidly. Few women drank at long-term risk. Factors associated with risky drinking varied with age; however, being a past or current smoker consistently increased the risk, and risks for smokers increased with age. Risky drinking was less likely to be practised by women providing care and needing help with daily tasks, or by pregnant women and those living with children. Discussion and Conclusions: Risky drinking behaviour should be addressed in younger women and in those who smoke. Interventions to reduce risky drinking, possibly in combination with reducing smoking, could be offered through general practice centres.

Relatively little is known about the extent to which young adults use the Internet as a health information resource and whether there are factors that distinguish between those who do and do not go online for health information. Objective: The aim was to identify the sociodemographic, physical, mental, and reproductive health factors associated with young women's use of the Internet for health information. Methods: We used data from 17,069 young women aged 18-23 years who participated in the Australian Longitudinal Study on Women's Health. Multivariable logistic regression was used to estimate the association between sociodemographic, physical, mental, and reproductive health factors associated with searching the Internet for health information. Results: Overall, 43.54% (7433/17,069) of women used the Internet for health information. Women who used the Internet had higher odds of regular urinary or bowel symptoms (OR 1.44, 95% CI 1.36-1.54), psychological distress (very high distress: OR 1.24, 95% CI 1.13-1.37), self-reported mental health diagnoses (OR 1.16, 95% CI 1.09-1.23), and menstrual symptoms (OR 1.25, 95% CI 1.15-1.36) than women who did not use the Internet for health information. Internet users were less likely to have had blood pressure checks (OR 0.85, 95% CI 0.78-0.93) and skin cancer checks (OR 0.90, 95% CI 0.84-0.97) and to have had a live birth (OR 0.74, 95% CI 0.64-0.86) or pregnancy loss (OR 0.88, 95% CI 0.79-0.98) than non-Internet users. Conclusions: Women experiencing "stigmatized" conditions or symptoms were more likely to search the Internet for health information. The Internet may be an acceptable resource that offers "anonymized" information or support to young women and this has important implications for health service providers and public health policy.

Recruitment of young people for epidemiologic research remains challenging, with marked decreases in the effectiveness of face-to-face, mail, and telephone recruitment methods. We report on the implementation and feasibility of an innovative and flexible approach used to recruit participants for a longitudinal cohort study about contraceptive use and pregnancy (the Contraceptive Use, Pregnancy Intention, and Decisions (CUPID) Study). Australian women aged 18-23 years were recruited using a range of online, networking, and offline methods, including social media (primarily Facebook (Facebook Inc., Menlo Park, California; http://www.facebook.com)), face-to-face events, distribution of promotional material, and media releases. Over the course of the 1-year recruitment period (beginning in September 2012), a total of 3,795 eligible women were recruited to complete the online survey, at a cost of approximately A$11 per participant. This sample was found to be broadly representative of the Australian population of women aged 18-23 years in terms of demographic characteristics, with the exception of an overrepresentation of tertiary-educated women (88.7% compared with 72.6%). This study demonstrated that although current recruitment strategies are required to be innovative and flexible in order to engage young people in epidemiologic research, representative samples can be achieved online at reasonable cost.

Background: Many epidemiological studies that focus on pregnancy rely on maternal self-report of perinatal outcomes. The aim of this study was to evaluate the agreement between self-reported perinatal outcomes (gestational hypertension with or without proteinuria, gestational diabetes, premature birth and low birth weight) in a longitudinal study and linked to administrative data (medical records). Methods: Self-reported survey data from the Australian Longitudinal Study on Women's Health was linked with the New South Wales Perinatal Data Collection. Agreement between the two sources was evaluated using percentage agreement and kappa statistics. Analyses were conducted at two levels by: i) the mother and ii) each individual child. Results: Women reliably self-report their perinatal outcomes (=87 % agreement). Gestational hypertension with or without proteinuria had the lowest level of agreement. Mothers' reports of perinatal outcomes were more reliable when evaluated by child. Restricting the analysis to complete and consistent reporting further strengthened the reliability of the child-specific data, increasing the agreement from >92 to >95 % for all outcomes. Conclusions: The present study offers a high degree of confidence in the use of maternal self-reports of the perinatal outcomes gestational hypertension, gestational diabetes, preterm birth and low birth weight in epidemiological research, particularly when reported on a per child basis. Furthermore self-report offers a cost-effective and convenient method for gathering detailed maternal perinatal histories.

Objective: To qualify the psychosocial burden of osteoarthritis for older women and identify factors perceived to assist with psychological adjustment to the disease. Methods: Women who indicated being diagnosed/treated for osteoarthritis in the previous three years in the fifth survey of the Australian Longitudinal Study on Women's Health provided the sampling frame. Participants were randomly sampled until saturation was reached using a systematic process. Thematic content analysis was applied to the 19 semi-structured telephone interviews using a realist framework. Results: The findings indicate that the emotional burden of osteoarthritis is considerable, and the process of psychological adjustment complex. Older women with osteoarthritis have psychological difficulties associated with increasing pain and functional impairment. Psychological adjustment over time was attributed primarily to cognitive and attitudinal factors (e.g. stoicism, making downward comparisons and possessing specific notions about the cause of arthritis). This was a dynamic 'day to day' process involving a constant struggle between grieving physical losses and increasing dependence amidst symptom management. Conclusion: The findings of this study add to the current understanding of the complex processes involved in psychological adjustment over time. Targeted interventions focused on assisting women with arthritis redefine self-concepts outside the confines of caring responsibilities, coupled with public health education programs around understanding the destructive nature of arthritis are required. Understanding the destructive and (potentially) preventable nature of arthritis may facilitate early detection and increased uptake of appropriate treatment options for osteoarthritis that have the ability to modify disease trajectories.

While grief, emotional distress and other mental health conditions have been associated with pregnancy loss, less is known about the mental health impact of these events during subsequent pregnancies and births. This paper examined the impact of any type of pregnancy loss on mental health in a subsequent pregnancy and postpartum. Data were obtained from a sub-sample (N = 584) of the 1973-78 cohort of the Australian Longitudinal Study on Women's Health, a prospective cohort study that has been collecting data since 1996. Pregnancy loss was defined as miscarriage, termination due to medical reasons, ectopic pregnancy and stillbirth. Mental health outcomes included depression, anxiety, stress or distress, sadness or low mood, excessive worry, lack of enjoyment, and feelings of guilt. Demographic factors and mental health history were controlled for in the analysis. Women with a previous pregnancy loss were more likely to experience sadness or low mood (AOR = 1.75, 95% CI: 1.11 to 2.76, p = 0.0162), and excessive worry (AOR = 2.01, 95% CI: 1.24 to 3.24, p = 0.0043) during a subsequent pregnancy, but not during the postpartum phase following a subsequent birth. These results indicate that while women who have experienced a pregnancy loss are a more vulnerable population during a subsequent pregnancy, these deficits are not evident in the postpartum. © 2014 Chojenta et al.

Background: Faced with the challenge of recruiting young adults for health studies, researchers have increasingly turned to the Internet and social networking sites, such as Facebook, as part of their recruitment strategy. As yet, few large-scale studies are available that report on the characteristics and representativeness of the sample obtained from such recruitment methods.

Objective A comprehensive life course perspective of women's experiences in obtaining and using contraception in Australia is lacking. This paper explores free-text comments about contraception provided by women born between 1973 and 1978 who participated in the Australian Longitudinal Study on Women's Health (ALSWH). Methods The ALSWH is a national population-based cohort study involving over 40,000 women from three age groups, who are surveyed every three years. An initial search identified 1600 comments from 690 women across five surveys from 1996 (when they were aged 18-23 years) to 2009 (31-36 years). The analysis included 305 comments from 289 participants. Factors relating to experiences of barriers to access and optimal contraceptive use were identified and explored using thematic analysis. Results Five themes recurred across the five surveys as women aged: (i) side effects affecting physical and mental health; (ii) lack of information about contraception; (iii) negative experiences with health services; (iv) contraceptive failure; and (v) difficulty with accessing contraception. Conclusion Side effects of hormonal contraception and concerns about contraceptive failure influence women's mental and physical health. Many barriers to effective contraception persist throughout women's reproductive lives. Further research is needed into reducing barriers and minimising negative experiences, to ensure optimal contraceptive access for Australian women.

This study examines differences in uptake of the Medicare items rolled out in 2006 under the 'Better Access Scheme' (BAS) between rural and non-rural Australian women. It compares differences in women's uptake of the BAS services by area of residence (ARIA+) across time using the Australian Longitudinal Study of Women's Health (ALSWH) survey data linked to Medicare data. Women aged 28-33 years at the time the BAS was introduced that responded to the self-reported question on depression/anxiety and consented to linkage of their survey data with Medicare data (n=4316). Participants were grouped by ARIA+according to BAS use, diagnoses of anxiety/depression but no BAS use and other eligible women. Across all areas, women born 1973-1978 with a self-reported diagnosis of depression/anxiety or having treatment under the BAS had a significantly lower mean mental health score compared to other women. Significantly more women living in non-rural areas had used at least one service provided under the BAS initiative compared to women in outer regional, inner regional or remotes areas (21% versus 18% versus 13% versus 7%, respectively), and across all areas, 12% of women reported having a diagnosis of depression/anxiety but not been treated under the BAS. While there is a gradual uptake of the new BAS services, a large percentage of women who have a diagnosis of depression/anxiety have not been treated under the BAS. The data suggest that women in urban areas have been better able to take up the services compared to non-urban women. © 2014 National Rural Health Alliance Inc.

Aim: This paper explored how gerontology experts described baby boomers, whether they challenged the popular image, and if they provided alternatives to the popularly reported baby boomer behaviours and characteristics. Methods: Qualitative interviews were conducted with ten experts from different areas across Australia. The interviews were semi-structured and guided by a 'sense-making' approach to explore the baby boomer construct and identify expert narratives that differed from the popularly tendered image. Results: The majority of experts were identified as baby boomers and made use of phrases associated with the popular baby boomer image, such as 'cashed up', 'reinventing retirement' and 'sea change'. Lifestyle and wealth were recognised as staple features of the popular image. To a lesser degree, the experts also recognised alternative characteristics and behaviours, including people with disabilities and those who struggle financially. Conclusions: Experts appeared to identify with the popular baby boomer label, but not necessarily the accompanying stereotypes.

Objectives. To examine: (i) the extent to which victims of intimate partner abuse (IPA) use complementary and alternative medicine (CAM) and (ii) the effects of CAM on their mental health. Methods. Medline, Scopus, and Web of Science were searched for studies measuring the extent of CAM use amongst victims of IPA and trials assessing the impact of CAM on mental health amongst this population. Risk of bias was assessed using the Cochrane collaboration tool. Results. No studies measuring the level of CAM use amongst IPA victims, and only three studies assessing the effect of CAM on the mental health of this population were identified. Two studies looked at yogic breathing, while one assessed the effect of music therapy. All three studies showed some beneficial effects; however, each had a small sample, brief intervention period, and no follow-up measurement and were considered to be at high risk of bias. Conclusions. The review found little evidence for the benefits of CAM for IPA victims. Findings suggest positive effects of music therapy and yogic breathing; however, methodological limitations mean that these results should be interpreted with caution. It is important that more research into the use and effects of CAM amongst this population are undertaken. © 2014 Luke Duffy et al.

Background: Clinical practice guidelines now recommend that women be asked about their past or current mental health as a routine component of maternity care. However, the value of this line of enquiry in increasing engagement with support services, as required, remains controversial. Aim: The current study aimed to examine whether assessment of past or current mental health, received with or without referral for additional support, is associated with help-seeking during pregnancy and the postpartum. Methods: A subsample of women drawn from the Australian Longitudinal Study on Women's Health (young cohort) who reported experiencing significant emotional distress during pregnancy (N = 398) or in the 12 months following birth (N = 380) participated in the study. Results: Multivariate analysis showed that women who were not asked about their emotional health were less likely to seek any formal help during both pregnancy (adjOR = 0.09, 95%CI: 0.04-0.24) and the postpartum (adjOR = 0.07, 95%CI: 0.02-0.13), as were women who were asked about these issues but who were not referred for additional support (antenatal: adjOR = 0.26, 95%CI: 0.15-0.45; postnatal: adjOR = 0.14, 95%CI: 0.07-0.27). However, considerable levels of consultation with general practitioners, midwives and child health nurses, even in the absence of referral, were evident. Conclusion: This study demonstrates that enquiry by a health professional about women's past or current mental health is associated with help-seeking throughout the perinatal period. The clinical and resource implications of these findings for the primary health care sector should be considered prior to the implementation of future routine perinatal depression screening or psychosocial assessment programmes. © 2014 Australian College of Midwives.

Objective To identify predictors of antenatal alcohol consumption among women who usually consume alcohol. Design Prospective cohort study. Setting Australian Longitudinal Study on Women's Health (ALSWH). Population or Sample A total of 1969 women sampled from the ALSWH 1973-78 cohort. Methods Women were included if they were pregnant in 2000, 2003, 2006 or 2009. The relationship between antenatal alcohol consumption and sociodemographics, reproductive health, mental health, physical health, health behaviours, alcohol guidelines and healthcare factors was investigated using a multivariate logistic regression model. Main outcome measures Alcohol use during pregnancy. Results Most (82.0%) women continued to drink alcohol during pregnancy. Women were more likely to drink alcohol during pregnancy if they had consumed alcohol on a weekly basis before pregnancy (odds ratio [OR] 1.47; 95% confidence interval [95% CI] 1.13-1.90), binge drank before pregnancy (OR 2.28; 95% CI 1.76-2.94), or if they were pregnant while alcohol guidelines recommended low alcohol versus abstinence (OR 1.60; 95% CI 1.26-2.03). Drinking during pregnancy was less likely if women had a Health Care Card (OR 0.63; 95% CI 0.45-0.88) or if they had ever had fertility problems (OR 0.64; 95% CI 0.48-0.86). Conclusions Most Australian women who drank alcohol continued to do so during pregnancy. Prepregnancy alcohol consumption was one of the main predictors of antenatal alcohol use. Alcohol guidelines, fertility problems and Health Care Card status also impacted antenatal alcohol consumption. © 2013 RCOG.