Application of trauma informed care for childbirth trauma: The clinical profile of Australian patients accessing a tertiary antenatal intervention

Application of trauma informed care for childbirth trauma: The clinical profile of Australian patients accessing a tertiary antenatal intervention | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Application of trauma informed care for childbirth trauma: The clinical profile of Australian patients accessing a tertiary antenatal intervention Kelli MacMillan, Catherine Greenhalgh, Dominique Cleary, Jacqueline Cahill, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6644068/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background. Despite global recognition of childbirth trauma, as well as identifiable factors in pregnancy that may increase its occurrence, there is an absence of accessible and cost-effective primary (i.e., before childbirth) antenatal intervention. This study introduces an antenatal intervention, Sensitive Care Birth Plans (SCBP), currently implemented at the (blinded for peer review) Women and Newborn Health Service (WNHS) (service) in Western Australia (service location) and provides the maternal and infant characteristics of women accessing it for childbirth trauma. Methods. Data was drawn from 126 patient files ( M = 30.34 years, 14.1–44.4 years) identified with SCBPs from January to December 2022 at WNHS (service) in a retrospective file review. Results. Most women were diagnosed with a neurotic, stress-related and somatoform disorder (85.3%). There were high prevalences of childhood and adulthood trauma (63.5% and 63.2%, respectively), childbirth trauma (64.3%) and perinatal loss (54.1%). High rates of service use for the sample, with a 79% ( p < .001) increased likelihood of infant admission to the Special Care Nursery, and elevated antenatal admission days ( M = 3.72, SD = 5.27), and caesarean section delivery recorded for 44.3% of women. Conclusions. By understanding the profile of women receiving SCBPs, this study may inform a future pilot study to explore the experience of this intervention. SCBPs have the potential to provide a model for perinatal services of equitable and effective antenatal psychological intervention to enhance maternal and infant outcomes and facilitate maternity care in the context of an increasing emphasis on positive childbirth experience. childbirth trauma antenatal intervention posttraumatic stress disorder post-childbirth trauma informed care Introduction Significant public interest and global attention has been directed towards the importance of positive childbirth experience (WHO; 1), with adverse implications of a traumatic childbirth on both the mother and infant ( 2 , 3 ). Whilst prevalence estimates range from 4.7% ( 4 ) to 44% ( 2 , 5 ), without effective and routine assessment capable of identifying women with childbirth trauma, estimates are not likely to capture the extent of occurrence ( 6 ), or the likelihood of childbirth trauma arising in clinical practice. Consequently, understanding childbirth trauma, and how it may present diagnostically, is necessary to support maternal mental health, fetal development, and effective delivery of maternity care. This paper is designed to present a comprehensive description of a cohort of women that have received a psychological antenatal intervention for childbirth trauma in the form of childbirth plans (i.e., Sensitive Care Birth Plans; SCBPs) at a women’s hospital in Australia. Although definitions of childbirth trauma may vary, it is based on the subjective experience of the individual ( 7 ), rather than external criteria or obstetric complexity. Childbirth trauma includes women diagnosed with posttraumatic stress disorder (PTSD) following childbirth, as well as those that experience subclinical or posttraumatic stress (PTS) or posttraumatic stress symptoms (PTSS). PTS or PTSS includes the diagnostic symptoms of PTSD but differs in the intensity, duration and impact on daily life. Diagnosis of PTSD requires symptom duration of more than one month, whereas PTS or PTSS is recognised as those symptoms directly after a traumatic event (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; DSM-V-TR; 8). PTSD is a trauma and stressor-related disorder in the DSM-V-TR ( 8 ) that involves the experience of a perceived threat to one’s own life or the life of another. For childbirth related PTSD, this may be characterised by nightmares or flashbacks about a previous childbirth, physiological responses to exposure to stimuli around pregnancy; childbirth or the birth, which can include being at the hospital; attending antenatal appointments; medical examinations; or reading about childbirth ( 9 ). Avoidance may present with difficulty answering questions about previous childbirth experience or the upcoming birth, with the possibility of medical care avoidance where women struggle to attend antenatal appointments because of childbirth related PTSD. A challenge for maternity care providers identifying women more likely to experience childbirth related PTSD, is the risk to life may not correspond to the subjective experience of the woman (e.g., "I will not get up again"; "will my baby live"; 10). This means women may not be identified when the childbirth trauma occurs or in subsequent pregnancy based on the medical experience or maternal outcomes of the woman. As such, screening for birth-related trauma and the engagement of mental health professionals to provide comprehensive assessment and diagnosis to those women with childbirth related PTSD is required. This approach is observed in multidisciplinary childbirth trauma teams in Norway ( 11 ) and Sweden ( 12 ). However, whilst 20–48% of women may rate their childbirth experience as traumatic ( 13 , 14 ), not all of those women will develop PTSD or PTSS post childbirth ( 5 ). Consequently, it is the identification of those women at increased likelihood of childbirth related PTSD that is central to the application of effective intervention to reduce the prevalence or chronicity of childbirth trauma. If untreated, the impact of childbirth trauma can be long lasting for the individual and their family ( 15 ). These adverse effects to the woman (i.e., mental health; intimate partner relationship; mother-infant relationship; 16, 17), and her infant (e.g., 18) are well documented ( 19 ). In the context of maternity care, childbirth trauma may translate to high rates of planned caesarean section preferences in subsequent pregnancies ( 11 ), or differences in pain relief during labour or cervical dilation for presentation at hospital, with women reporting increased fear of childbirth less likely to present in active labour ( 20 ). Childbirth trauma may require high levels of staff support and resources to treat and overcome, with increased filing of patient complaints cases a potential outcome of negative birth experience ( 9 ). With increasing presentation of childbirth trauma, higher demand for intervention in hospital and community settings has followed ( 21 ), and emerging evidence of effective postnatal psychological intervention to treat PTSD or PTS after childbirth ( 6 ). While important, these secondary interventions (i.e., treatment provided after birth and identification of trauma symptoms; 9), do not address the challenges of delivering maternity care to a woman in pregnancy where she presents with childbirth related PTSD or PTS or similarly, experiences of (non-childbirth related) trauma or mental health concerns impacting on the administration of medical care. The alternative is to deliver primary prevention intervention (i.e., antenatal treatment for women with pre-existing factors that may increase the likelihood of childbirth trauma; 9), which is capable of integration into hospital and clinical settings to support delivery of care to the woman and optimal maternal and infant outcomes. Yet current evidence for primary prevention intervention for childbirth trauma is far more limited ( 11 , 22 – 25 ) with those studies that have been conducted involving low-risk participants, and a lack of examination of women at higher risk of childbirth trauma by reason of complex medical and mental health conditions and subsequent comorbidities. The potential for primary prevention intervention for childbirth trauma is facilitated by established risk factors identifiable in pregnancy that may increase the likelihood of childbirth trauma ( 26 ). Meta-analysis of 50 empirical papers identified these factors as: depression, PTSD history, childbirth fear, pregnancy complications, lack of support, dissociation, obstetric intervention, poor coping skills, and stress exposure ( 27 ). Also identified is unplanned caesarean section ( 28 , 29 ), operative vaginal birth ( 28 ), method of placenta removal ( 30 ), pain intensity ( 31 ), and lack of concordance between desired and actual type of birth ( 30 ). With knowledge of these factors, it follows that primary prevention intervention in pregnancy may be applied to treat women and reduce the likelihood of childbirth trauma postnatally, or at least, mitigate the chronicity of childbirth trauma symptoms. However, recent systematic review of available antenatal interventions for childbirth trauma identified only 14 studies, and did not identify any reports of existing interventions implemented with women with mental illness or PTSD history (under review; 32). Despite limited evidence based primary prevention interventions for childbirth trauma, the existing studies indicate preliminary efficacy (under review; 32). Available interventions include: cognitive behavioural therapy ( 33 ); eye movement desensitisation and reprocessing (EMDR; 34, 35); childbirth plans ( 11 , 12 , 23 , 24 ); haptotherapy and hypnosis ( 36 , 37 ); trauma-informed care ( 33 , 38 ); and antenatal education ( 20 , 22 , 23 , 39 ). Treatment effectiveness of childbirth plans shows increased rates of positive childbirth experience, childbirth control and mastery, participation, and self-efficacy ( 11 , 12 , 23 , 24 ). Reduced PTSD symptoms are noted from antenatal education ( 20 , 22 , 23 , 25 ). Despite the evidence offered by these studies, to the best of our knowledge, the effectiveness of antenatal intervention for childbirth trauma on a sample of women with mental health diagnoses has yet to be tested. One such primary prevention intervention currently implemented with individuals with mental health diagnoses identified in pregnancy as at risk of childbirth trauma, is at the (blinded for peer review) Women and Newborn Health Service (WNHS) (service) at King Edward Memorial Hospital (KEMH) (hospital) in Western Australia (WA) (hospital site location). Sensitive Care Birth Plans (SCBPs) are an enduring document developed during a collaborative process between clinician and woman with individualised and unique strategies to facilitate trauma-informed care. The SCBP is cost effective and efficient, with delivery provided in one psychotherapy session (which may be in the context of longer-term psychotherapy), and no additional training for the mental health clinician. Whilst this intervention is implemented clinically, little is known about the clinical profile of the women receiving the intervention. Our study This study aims to describe the common characteristics of women accessing SCBPs at one tertiary hospital site WNHS, WA (service). This will establish a clinical profile for the application of SCBPs and potentially facilitate antenatal identification of women who may be at risk of childbirth trauma. The SCBP intervention has the potential to provide a model for other services of equitable, cost-effective, and evidence-based antenatal intervention that can enhance maternal and infant outcomes in the context of childbirth and the postpartum. In this paper, we address the following three objectives: To identify the sociodemographic and mental health characteristics of the patients utilising the sensitive birth care plans (SCBPs) at WNHS (service) during the period of January 2022 to December 2022. To identify the service use characteristics of the women utilising the SCBPs during the period of January 2022 to December 2022. Of the women utilising the SCBPs in the service during the period of January 2022 to December 2022, to assess birth and neonatal outcomes. Method Design and Sample For this retrospective medical file review, a cohort of 126 women were included, which is the total number of SCBPs that were provided in the context of antenatal treatment between 1 January 2022 and 31 December 2022 at WNHS, Mental Health Service: Outpatient and Consultation Liaison (service blinded for peer review). The cohort were identified by a review of all Sensitive Care Plans provided by researchers in the team who are also treating clinicians at the service (J.C., K.D., K.K.M., C.B., and D.C). All data extraction regarding patients identified from their SCBPs involved review of physical medical files, with treatment occurring before the introduction of digital medical records at the service. This study has Human Research Ethics Committee (HREC) approval from the Department of Health Western Australia (RGS0000006343), and cross-institutional approval from Murdoch University’s HREC (2024/005). Inclusion and Exclusion Criteria Inclusion criteria for the retrospective file review included: ( 1 ) past or current patients of the WNHS; (service) ( 2 ) SCBPs dated between 1 January 2022 and 31 December 2022; ( 3 ) the SCBP was delivered in the context of antenatal intervention for childbirth trauma and, ( 4 ) the SCBP was provided during psychological treatment at the WNHS (service). The date for selection of the files was nominated based on the introduction of documentation by WNHS (service) at that time indicating integration of the intervention within the service. Exclusion criteria included: ( 1 ) women who had an SCBP for purposes other than the prevention of birth trauma, PTSD, or trauma symptoms post childbirth; and ( 2 ) women whose perinatal services and/or birth did not take place at KEMH (service). Procedure and Patient Data The retrospective file review of eligible participants’ medical files occurred between March 2023 and April 2023. The review was conducted by researchers J.C., K.D., K.K.M., C.W., C.B. and D.C., with any disagreement regarding data extraction resolved following consultation with researcher S.W. There were no outstanding disagreements. Data was extracted on an agreed list of maternal and infant variables. The variable extraction list was finalised following consensus amongst researchers (J.C., K.D., K.K.M., C.W., C.B., D.C, S.W.) and the HREC. Data from the files was entered into a WA Health (service)-hosted REDCap project accessible only to investigators. The data extracted included characteristics to describe participants’ sociodemographic, mental health, experiences of trauma, health service use, and birthand neonatal outcomes. Sociodemographic Characteristics Sociodemographic data extracted included participant age at first booking, educational attainment, parity, and substance use. Mental Health Mental health data included a participant-reported history of mental health diagnosis and prior admission to an inpatient mental health service. A current mental health diagnosis, consistent with the International Classification of Diseases (ICD-10) were extracted from participant files. Data for mental health symptoms and psychosocial risk screeners were also extracted. Maternal depressive and anxious symptoms. The EPDS ( 40 ) is incorporated as part of routine antenatal screening for depression at KEMH (service) for all women at two antenatal visits. The EPDS is a ten-item self-report measure and response scale of 0 to 3. Responses are summed, with a total score ranging from 0 to 30 and higher scores indicative of more depressive symptoms. Three items can be scored separately to assess anxiety, with a sum score ranging 0 through 9 ( 41 ). The EPDS has been validated for application with Australian postpartum women ( 42 ). Women who score 13 or higher are considered as being at an elevated risk of having a depressive disorder, which has been recommended empirically due to high sensitivity and specificity with respect to accuracy in identifying clinical cases. Psychosocial risk factors. The ANRQ ( 43 ) is incorporated into routine antenatal screening of psychosocial risk at KEMH(service). The ANRQ is a 14-item self-report scale designed to measure psychosocial risk factors in pregnancy, including mental health history, trauma history, social supports, and current stressor exposures. Responses are summed with a total score ranging between 5 and 67, with higher scores denoting higher psychosocial risk. The ANRQ has been validated for routine antenatal screening in maternity clinical settings, with a score of 23 used to indicate increased psychosocial risk ( 43 , 44 ). Trauma Traumatic experiences data extracted included history of and forms of childhood trauma (including sexual abuse, and physical and emotional abuse and neglect) and other trauma experienced as an adult (including sexual and/or physical trauma, emotional abuse, emotional and physical neglect, and coercive control). Data was also extracted for prior pregnancy loss (i.e., miscarriage; abortion; fetal loss or stillbirth or neonatal death), and prior birth trauma. Health Service Use Health service data extracted included the clinic providing antenatal care, the number of antenatal hospital admissions and length of stay for each, length of postnatal admission following birth, and the number of psychotherapy sessions, both antenatally and postnatally, scheduled and attended at the Mental Health Service at KEMH (service). Birth and Neonatal Outcomes Birth and neonatal outcome data extracted included induction and augmentation, mode of birth, gestation at birth, and admission to a special care nursery or neonatal intensive care nursery (SCN/NICU). Statistical analyses All statistical analyses were performed using Stata 16.0 (StataCorp, 2019). Demographic data will be analysed using descriptive statistics. For all objectives, data were analysed primarily using descriptive statistics, presented as frequencies (i.e., n and %) or measures of central tendency (i.e., M and SD for normally distributed numerical data, or Mdn and IQR for non-normally distributed numerical data). Missing data is a common issue with medical record data extraction; as such, we report missing data for each variable and clearly indicate where reported percentages are adjusted for the number of cases with missing data in the denominator (i.e., valid percent). Where possible, a comparison between the descriptive statistic for the SCBP cohort is compared to all women giving birth and infants born at KEMH (service) during the study period, 1 January 2022 to 31 December 2022 ( N = 5,401, N = 5,580 babies). For Objective 3 specifically, birth and neonatal outcomes of the SCBP cohort are compared to all births at KEMH (service) during the study period. The prevalence of outcomes will be reported for the two samples and compared inferentially using Risk Ratios (RR) with associated 95% confidence intervals (95% CIs) and exact p -values. Statistical significance for RR s is assessed at p < .05. Results Sociodemographic Profile of Patients with a SCBP Women who received the SCBP intervention during their antenatal care at KEMH (service) were an average of 30.34 years of age ( SD = 7.04), ranging between 14.1 years and 44.4 years of age, which was slightly younger than the average of all pregnant women at KEMH (service) during the study period ( M = 32.16 years, min = 14 years, max = 49 years). There were significantly more participants ( n = 11/126, 8.73%) aged less than 18 years in the SCBP cohort compared to all pregnant women at KEMH (service) during the study period ( n = 64/5,401, 1.18%; χ 2 [1] = 51.83, p < .001). Table 1 presents other select socioeconomic characteristics of the SCBP cohort. A university degree was the most common level of educational attainment amongst participants (36.1%); however, educational attainment was not identified for 14.3% of participants. Substance use was identified in almost one-fifth of women (18.8%) and a similar proportion were nulliparous (19.8%). For multiparous women, gravidity ranged between two and 14 pregnancies ( Mdn = 3, IQR = 2–4). Mental Health Profile of Patients with a SCBP Table 2 presents mental health characteristics of the SCBP cohort at KEMH(service). More than three-quarters of participants (78.6%) were identified as having a history of mental health difficulties, with 14 (11.7%) having a history of inpatient admission for mental health difficulties. A current mental health diagnosis was not identified during the review of 24 participant files (19.1%). For the 102 participants with an ICD-10 block-level mental and behavioural disorder recorded in their file, neurotic, stress-related and somatoform disorders (F40–F48) were the most prevalent diagnoses (85.3%). Within this category (F40–48), reaction to severe stress, and adjustment disorders (F43) were the most common ( n = 37, 36.3%), with PTSD (n = 24, 23.5%) the most common F43 diagnosis. The median EPDS score recorded for 108 of 126 patients (85.7%), administered during the first appointment, was 10 (IQR = 5–15) and ranged between 0 and 26. For the anxiety subscale of the EPDS, the median was 5 (IQR = 3–7), ranging between 0 and 9. The median ANRQ score recorded for 79 of 126 participants (62.7%), administered during the first appointment was 31 ( IQR = 23–40) and ranged between 7 and 57. Using the cut off score of 23 or above, 76.0% ( n = 60/79) of participants who completed an ANRQ were identified to be at psychosocial risk. In contrast, 36.1% ( n = 39/108) of participants who completed EPDS scores 13 or above and were identified as having an elevated risk of depression. Of the 73 participants who completed both the EPDS and the ANRQ, all 25 (34.3%) identified by the EPDS as having an elevated risk of depression were also identified by the ANRQ as being at increased psychosocial risk; however, there were 30 (41.1%) identified at increased psychosocial risk by the ANRQ but not at increased risk of depression by the EPDS alone. Trauma History Profile of Patients with a SCBP Table 3 presents experiences of childhood and current traumas, prior pregnancy loss and past birth trauma for the SCBP cohort. Extracting data from participant files for the childhood and current traumatic experiences variables proved difficult, with 23.8% and 30.1% missing data, respectively. However, of those with data, 63.5% were identified as having experienced trauma during their childhood and 63.2% were identified as having experienced trauma during adulthood. Almost half of multiparous participants ( n = 101) had experienced prior pregnancy loss (44.1%), with prior miscarriage being the most prevalent experience of loss (30.6%). Further, 62.4% of multiparous women were identified as having reported prior birth trauma; however, less than half of the women who reported prior birth trauma reported receiving treatment specifically for their birth trauma experience (n = 28/63, 43.8%). Health Service Use Profile of Patients with a SCBP Table 4 displays service use characteristics for the SCBP cohort. Women in the SCBP cohort were managed mostly by obstetric led antenatal clinics (20.2%) and a maternal-fetal medicine clinic (18.5%) and low and mixed-risk midwifery-led continuity of care through the Family Birthing Centre/Midwifery Group Practice (12.9%). More than one-quarter ( n = 33/116, 28.4%) of the SCBP cohort had at least one antenatal medical admission prior to their admission for birthing (i.e., ≥ 2 antenatal medical admission). The collective number of antenatal medical admission days ranged between 1 and 36, with a median of 2 days ( IQR = 1–15). The majority of the SCBP cohort were in hospital for between one- and five-days following birth (81.3%). The number of Mental Health Service appointments booked and attended by SCBP cohort women varied substantially; however, the medians for appointments booked ( Mdn = 10) and attended ( Mdn = 9) were similar. The majority of SCBP cohort women attended 80% or more of their booked appointments (n = 106/125, 84.8%). Birth and Neonatal Outcomes of Patients with a SCBP Table 5 displays birth and neonatal outcomes for participants in the SCBP cohort at KEMH (service), compared to all women and babies at KEMH (service) during 2022. Across the limited data we collected, birth and neonatal outcomes were similar for the SCBP baseline cohort compared to all pregnancies at KEMH (service) during 2022, except for SCN/NICU admissions of infants. Infants born to women who accessed the SCBP intervention were at a 79% significantly greater risk of admission to SCN/NICU compared to all infants born at KEMH (a tertiary referral maternity hospital that accepts referrals for complex pregnancies for the state) during 2022 ( OR = 1.79 [ 95% CI : 1.42, 2.26], p < .001). Discussion This study is the first to identify the profile of Australian women who accessed an antenatal intervention for childbirth trauma at a tertiary perinatal service. In the cohort of 126, the proportion of adolescent pregnancies was higher relative to all women birthing at the service in the same year, with substance use identified in one-fifth of the cohort. Clinically, neurotic, stress-related and somatoform disorders, including PTSD, were the most prevalent psychiatric disorders, identified as present in 85 percent of the sample. In addition, almost all women had at least one diagnosed physical condition. Routine screening measures showed elevated psychosocial risk in three-quarters of the cohort, compared to an elevated risk of depression in approximately one-third of the women. Two-thirds of the cohort reported childhood or adult trauma, with another two-thirds of multiparous women reporting prior birth trauma and half experiencing prior pregnancy loss. Service-related characteristics revealed that more than one-quarter of the sample had at least one antenatal medical admission prior to admission for birthing. Treatment engagement was generally high; with over 80 percent of women attending all booked psychological appointments. Infants of women in this sample were at higher risk of admission to the SCN/NICU compared to all infants born at the service in the same year. Although elective caesarean section rates were elevated relative to all birth at the service in the same year, this trend did not reach statistical significance. These identified characteristics, often presenting as a complex interaction for many women, represent risk factors that are identifiable antenatally and capable of being targeted through intervention before childbirth to enhance maternal and infant outcomes. Prior traumatic experience was a key characteristic of the cohort with prevalence rates of approximately 60% for trauma in childhood, adulthood, and childbirth. Of the five domains of childhood trauma, childhood sexual abuse was most prevalent, identified in more than half the cohort, with one-quarter reporting childhood emotional abuse. Childhood trauma is well established as a risk factor for mental health disorders ( 45 ), with the neurobiological stress regulation system more vulnerable at sensitive and critical periods following early life exposure to adversity and trauma ( 46 , 47 ). Recently, Porthan et al. ( 48 ) found that childhood emotional abuse and neglect along with a higher total burden of childhood trauma, were associated with an increased fear of childbirth. Whilst this highlights the increased likelihood of fear of childbirth in the context of childhood trauma, it also represents a current challenge for the childbirth trauma literature with the outcome of fear of childbirth frequently applied to measure the effectiveness of childbirth trauma interventions (e.g., 22, 34, 36). Yet a sample of women with fear of childbirth is not representative of women with PTSD post-childbirth or subthreshold PTSD symptoms. In addition, rates of prior childbirth trauma were elevated in our sample, with two-thirds of multiparous women identified as having a previously traumatic birth, compared to international estimates ranging between one and 44 percent ( 3 , 4 ). Collectively, these findings describe a population characterised by significant, complex past and current trauma, who are at risk of re-traumatisation during childbirth. This demonstrates the necessity of early identification of antenatal patients with prior trauma experience so that trauma-informed care can be facilitated within maternity services. The prevalence of prior pregnancy loss in this cohort highlights the salience of this experience for subsequent pregnancies ( 49 , 50 ). This finding also indicates the increased likelihood of childbirth trauma where pregnancy loss has been identified, and the need for healthcare professionals to be aware of prior pregnancy loss and the possible impact on other pregnancies, whether it is miscarriage, stillbirth, or abortion history. Almost half the women in this cohort reported a prior pregnancy loss. Although the prevalence of miscarriage in our sample was similar to what has been reported in community samples (24% verses 19%) ( 51 ), the prevalence of both abortion (i.e., 6.5% verses 1.73%; 52) and stillbirth (i.e., 7.3% verses 0.72%; 53) were markedly higher in our sample compared to Australian population estimates. Outside of these findings, we are not aware of any other studies that have previously identified pregnancy loss a risk factor for childbirth trauma (e.g., 27). Whilst more recently we can see acknowledgement of the need for trauma-informed care in the context of perinatal loss ( 54 ), there has been a documented failure to recognise the long-lasting emotional effect of perinatal loss on women, with maternal identity not consistently acknowledged for women after stillbirth ( 55 ), and a lack of perceived social support increasing feelings of isolation and grief ( 56 ). A recent review on pregnancy loss and perinatal mental health ( 57 ) highlighted the variation in the individual response to pregnancy loss. Factors including cultural and religious beliefs, race, and age, as well as the response of medical providers were identified as influencing the likelihood and chronicity of the psychological impact of pregnancy loss. That said, pregnancy loss is an identifiable antenatal factor and information that is consistently available in medical records; thus, improving the awareness of this as a potential risk for childbirth trauma may facilitate increased access to trauma-informed care for those women in subsequent pregnancies. The routine completion and documentation of screening measures during antenatal care is a critical step for the identification of women at risk of childbirth trauma who may benefit from preventative psychological intervention during pregnancy. Documentation of the EPDS and the ANRQ was not consistent in this cohort, with almost 15% not having an EPDS recorded and almost 40% not having an ANRQ recorded; this is despite both being recommended for use in combination as screening measures in Australian national guidelines ( 42 , 43 , 58 ). For those women where both screening measures were recorded, over 40% identified as having an elevated psychosocial risk on the ANRQ did not have scores indicating elevated risk of depression on the EPDS. This differential highlights the limitations of relying exclusively on a screening tool for depression to screen for what is a broad and diverse spectrum of illness and experience. The EPDS has become widely relied upon as the only measure of depression ( 59 ), despite recommendations for its application to not to be relied upon in the absence of other screening tools ( 60 ). With nearly half of the cohort missing a completed ANRQ, a consideration of the barriers to screening for psychosocial adversity is required. What is clear from these results is that antenatal psychosocial screening is important for this population and that screening for depression alone will result in many women at risk of childbirth trauma falling through service gaps. These findings are a mandate for the review and development of effective antenatal screening to identify women who are at risk of childbirth trauma. High levels of service demand are represented in this sample for the woman and the infant. Compared to Australian population estimates, infants in this cohort were more than two times more likely to be admitted to the SCN or NICU (i.e., 37.4% verses 13.15%, respectively; 61). When compared to all infants born at the service in the same year, infants born to women in the cohort were nearly 80 percent more likely to be admitted to an SCN/NICU. This increased risk remained statistically significant even after removing women attending the service’s complex antenatal care clinics (i.e., preterm, complex medical care, and adolescent). Research has grappled with the impact of the NICU experience for maternal mental health with higher rates of depression and anxiety ( 62 , 63 ), as well as clinical PTSD and PTSS ( 64 , 65 ). With high rates of trauma past and current, together with the increased likelihood of exposure to another stressful event such as an infant admission to the NICU, these findings highlight the potential for this cohort to experience multiple traumas across the perinatal period. Given evidence that exposure to multiple types of adversity is a stronger predictor of psychopathology then severe or chronic single traumatic experiences ( 66 – 68 ), the vulnerability of women accessing antenatal intervention for childbirth trauma is again demonstrated. Limitations A challenge of this study involved the missing data in participant files, which may more widely indicate that information about women at risk of childbirth trauma is not consistently collected during antenatal screening. Consultation with the health care clinicians that provide the screening needs to occur to identify the barriers to administration, with focus group consultation a next step. This is particularly important in considering equitable access to supports and services, with referral of women with high risk of childbirth trauma potentially less likely if screening for risk factors is not conducted. Conclusion This study aimed to describe the clinical cohort of women accessing a primary prevention intervention for childbirth trauma at a tertiary women’s hospital in Western Australia (service location). Maternal and infant characteristics highlighted the complex interaction of risk factors for women accessing childbirth trauma intervention including stress-related, anxiety, and PTSD mental health diagnoses, medical comorbidity, childhood and adult trauma, pregnancy loss, and substance use. The rates of service use required for this cohort is also evident in the increased likelihood of NICU admission as well as the trending higher rates of planned elective caesarean section. Different outcomes may be achieved in reducing the chronicity and likelihood of occurrence of childbirth trauma where antenatal risk factors are identified, and antenatal intervention can be provided. This requires a multidisciplinary approach, like those modelled in Sweden and Norway, where screening identifies higher rates of childbirth fear for referral to antenatal childbirth trauma or fear of childbirth teams, capable of providing treatment to enhance the experience of childbirth as well as facilitating optimal medical outcomes for both the woman and child. Declarations Ethical approval and consent to participate This study has Human Research Ethics Committee (HREC) approval dated 12 December 2023 from the Department of Health Western Australia (RGS0000006343), and cross-institutional approval from Murdoch University’s HREC dated 1 February 2024 (2024/005). The data analysed during the current study did not involve consent to participate because it was extracted from medical records as per ethics and hospital approvals. Consent for publication The data contained in this manuscript is deidentified and anonymous. No individual identifying information can be applied. Availability of data and materials The data analysed during the current study is not publicly available because it was extracted from medical records and as per ethics, and hospital approvals, the data is not available for sharing. Competing interests The authors declare they have no competing interests. Funding Open access funding was provided by the Women and Newborn Health Service, King Edward Memorial Hospital, Subiaco, Western Australia. Author’s contributions KKM: Conceptualisation; methodology; data collection; analysing and interpreting results; writing of manuscript; reviewing of manuscript; supervision. CFG: Analysing and interpreting data and results; writing – review and editing. SJW: Conceptualisation; methodology; analysing data; interpreting results; writing of manuscript; supervision. DBC: Conceptualisation; methodology; data collection; interpreting results; writing – review and editing. KD: Conceptualisation; data collection; writing – review and editing. JC: Conceptualisation; data collection; writing – review and editing. CB: Conceptualisation; data collection; writing – review and editing. CW: Data collection. ZB: Data interpretation; writing – review and editing. SWW: Data interpretation; writing – review and editing. Acknowledgements The authors would like to acknowledge the support of the Women and Newborn Health Service (WNHS) of Western Australia in conducting this research and supporting the establishment of the Childbirth Trauma Research Project. We also want to acknowledge the support of the Directors of WNHS in the publication of these meaningful findings, as well as the clinicians and their tireless efforts to support women during this critical time. And most importantly, we acknowledge all individuals who have birthed a baby – this research is for you. References WHO WHO. WHO recommendations: Intrapartum care for a positive childbirth experience. Geneva; 2018 2018. Dekel S, Stuebe C, Dishy G. 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BMC pregnancy and childbirth. 2021;21:1-10. Hamby S, Elm JH, Howell KH, Merrick MT. Recognizing the cumulative burden of childhood adversities transforms science and practice for trauma and resilience. American Psychologist. 2021;76(2):230. Haahr-Pedersen I, Ershadi AE, Hyland P, Hansen M, Perera C, Sheaf G, et al. Polyvictimization and psychopathology among children and adolescents: A systematic review of studies using the Juvenile Victimization Questionnaire. Child Abuse & Neglect. 2020;107:104589. Lätsch DC, Nett JC, Hümbelin O. Poly-victimization and its relationship with emotional and social adjustment in adolescence: Evidence from a national survey in Switzerland. Psychology of violence. 2017;7(1):1. Tables Table 1. Sociodemographic characteristics of patients utilising Sensitive Care Birth Plans at KEMH (service) ( N =126) n %^ Maternal education (missing=18, 14.3%) Not known 32 29.6 Left school prior to Year 12 11 10.2 Secondary School Certificate 9 8.3 TAFE or Certificate 17 15.7 University 39 36.1 Substance use (missing = 9, 7.1%) 22 18.8 Primiparous 25 19.8 ^Valid percent adjusted for missing in the denominator. Table 2. Mental Health Characteristics of Patients Utilising Sensitive Care Birth Plans at KEMH (service) ( N =126) n %^ Mental health history 99 78.6 History of inpatient admission for mental health (missing=6, 4.8%) None 106 88.3 MBU in last 12 months 2 1.7 Hx of MBU 3 2.5 Other 9 7.5 Current mental health diagnosis (missing=24, 19.1%) 102 100.0 F20-F29: Schizophrenia, schizotypal and delusional disorders 1 1.0 F30-F39: Mood (affective) disorders 27 26.5 F40-F48: Neurotic, stress-related and somatoform disorders 87 85.3 F50-F59: Behavioural syndromes associated with physiological disturbances and physical factors 1 1.0 F60-F69: Disorders of adult personality and behaviour 9 8.8 F90-F98: Behavioural and emotional disorders with onset usually occurring in childhood and adolescence 3 2.9 Z55-Z65: Persons with potential health hazards related to socioeconomic and psychosocial circumstances 2 2.0 Number of mental health diagnoses (missing=24, 19.1%) 1 64 62.8 2 29 28.4 3 4 3.9 4 4 3.9 5 1 1.0 ^Valid percent adjusted for missing in the denominator. Table 3. Trauma History for Patients Utilising Sensitive Care Birth Plans at KEMH (service) ( N =126) n %^ Childhood trauma (missing=30, 23.8%) 61 63.5 Sexual abuse 28 29.2 Physical abuse 24 25 Emotional abuse 24 25 Physical neglect 3 3.1 Emotional neglect 13 13.5 Childhood trauma, unspecified 10 10.4 Current trauma (missing=39, 30.1%) 55 63.2 Sexual 10 11.5 Physical 27 31 Emotional 25 28.7 Coercive control 4 4.6 Unspecified 8 9.2 Prior pregnancy loss multiparous women only n=101 (missing=3, 3.0%) 53 54.1 Miscarriage 30 30.6 Fetal death in utero 7 7.1 Stillbirth without MTOP 9 9.2 Abortion 7 7.1 Medical 4 57.1 Social 1 14.3 Unknown 1 14.3 None 45 45.9 Prior birth trauma, multiparous women only n=101 (missing=3, 3.0%) 63 64.3 Treatment for prior birth trauma, n=63 (missing=5, 7.8) 28 48.3 ^Valid percent adjusted for missing in the denominator. Table 4. Health Service use characteristics for the Sensitive Care Birth Plan Baseline Cohort ( N = 126) n % Antenatal clinic (missing = 2, 1.6%) Maternal-Fetal Medicine Service (GOLD) 23 18.5 Perinatal Loss Service (PLS) 1 0.8 Pregnancy Drugs and Alcohol Service (WANDAS) 10 8.1 Preterm Birth Prevention 5 4 Childbirth and Mental Illness Service (CAMI) 1 0.8 Adolescent Pregnancy 13 10.5 Red 25 20.2 Blue 10 8.1 Green 11 8.9 Orange 6 4.8 Community Midwifery Program (CMP) 3 2.4 Family Birthing Centre (FBC)/Midwifery Group Practice (MGP) 16 12.9 Number of antenatal medical admissions (missing=10, 7.9%) 0 admissions 1 0.9 1 admission 82 70.7 2 admissions 19 16.4 3 admissions 6 5.2 4 admissions 4 3.4 5 admissions 1 0.9 6 admissions 2 1.7 8 admissions 1 0.9 Length of postnatal admission following birth (missing=3, 2.4%) 10 days 2 1.6 Mdn (IQR) Min-Max Number of Mental Health Service Appointments Booked (missing=1) 10 (5 - 16) 1-45 Number of Mental Health Service Appointments Attended (missing=1) 9 (4 - 14) 1-43 Percentage of Mental Health Service Appointments relative to Booked (missing=1) 100.0 (88.2 - 100.0) 40 - 100 ^Valid percent adjusted for missing in the denominator. Table 5. Delivery and neonatal outcomes for patients utilising Sensitive Care Birth Plans at KEMH (service)and all KEMH (service) pregnancies. SCBP Baseline Cohort ( N =126) All KEMH (service) ( N =5,401) Risk Ratio (95% CI ) n %^ n %^ Spontaneous labour (missing = 1, 0.8%) 42 33.6 2,196 40.7 0.83 (.64, 1.06) Induction of labour (missing = 1, 0.8%) 47 37.6 1,955 36.2 1.04 (.83, 1.31) Augmentation of labour (missing=2, 1.6%) 16 12.9 555 10.3 1.26 (.79, 2.00) Mode of birth (missing = 4, 3.2%) Standard vaginal delivery 57 46.7 2,715 50.3 .93 (.77, 1.13) Assisted delivery 11 9.0 648 12.0 .75 (.43, 1.33) Assisted - forceps 5 4.1 - - - Assisted - vacuum 6 4.9 - - - Caesarean section 54 44.3 2038 37.7 1.17 (.96, 1.44) Unscheduled 27 22.1 1147 21.2 1.04 (.74, 1.46) Category 1: Urgent threat, delivery within 30 minutes 4 3.3 - - - Category 2: Maternal or fetal compromise, delivery within 60 minutes 13 10.7 - - - Category 3: Earlier than planned by no compromise 10 8.2 - - - Category 4: Elective time that works for woman and service 27 22.1 891 16.5 1.34 (.96, 1.88) Preterm labour 24 19.0 1,003 18.6 1.03 (.71, 1.48) SCN/NICU admission (missing = 3, 2.4%) 46 37.7 1,128 20.9 1.79*** (1.42, 2.26) ^Valid percent adjusted for missing in the denominator. ***p<.001 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6644068","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":489156968,"identity":"30758e3a-d449-449d-8453-86dd7779117f","order_by":0,"name":"Kelli MacMillan","email":"data:image/png;base64,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","orcid":"","institution":"Murdoch University","correspondingAuthor":true,"prefix":"","firstName":"Kelli","middleName":"","lastName":"MacMillan","suffix":""},{"id":489156969,"identity":"a48bcf58-477d-4288-b2a9-59ba642eb2f7","order_by":1,"name":"Catherine Greenhalgh","email":"","orcid":"","institution":"Murdoch University","correspondingAuthor":false,"prefix":"","firstName":"Catherine","middleName":"","lastName":"Greenhalgh","suffix":""},{"id":489156971,"identity":"a5ea2284-501e-4a51-9cd0-28b5758ac44f","order_by":2,"name":"Dominique Cleary","email":"","orcid":"","institution":"King Edward Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Dominique","middleName":"","lastName":"Cleary","suffix":""},{"id":489156973,"identity":"5f26a116-63a7-411a-8a19-54f7b4c59e93","order_by":3,"name":"Jacqueline Cahill","email":"","orcid":"","institution":"King Edward Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jacqueline","middleName":"","lastName":"Cahill","suffix":""},{"id":489156974,"identity":"a7a0d00d-e7e3-4075-9322-a386c8935f1b","order_by":4,"name":"Kellie Dedman","email":"","orcid":"","institution":"King Edward Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kellie","middleName":"","lastName":"Dedman","suffix":""},{"id":489156975,"identity":"8625c49a-42c1-4bfa-b825-efc887b75896","order_by":5,"name":"Chloe Weir","email":"","orcid":"","institution":"King Edward Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chloe","middleName":"","lastName":"Weir","suffix":""},{"id":489156976,"identity":"fd9eb827-e596-43c6-9ddd-67919b9a444e","order_by":6,"name":"Carolyn Bright","email":"","orcid":"","institution":"Murdoch University","correspondingAuthor":false,"prefix":"","firstName":"Carolyn","middleName":"","lastName":"Bright","suffix":""},{"id":489156977,"identity":"ba936cef-4be0-4e9a-b3f1-15e885118b4d","order_by":7,"name":"Scott White","email":"","orcid":"","institution":"King Edward Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Scott","middleName":"","lastName":"White","suffix":""},{"id":489156978,"identity":"d1b58a43-c3f0-475a-870b-c827c8afd502","order_by":8,"name":"Zoe Bradfield","email":"","orcid":"","institution":"Curtin University","correspondingAuthor":false,"prefix":"","firstName":"Zoe","middleName":"","lastName":"Bradfield","suffix":""},{"id":489156979,"identity":"2b484ec1-989f-4020-b34d-32b3880b50c1","order_by":9,"name":"Stuart Watson","email":"","orcid":"","institution":"King Edward Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Stuart","middleName":"","lastName":"Watson","suffix":""}],"badges":[],"createdAt":"2025-05-12 07:43:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6644068/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6644068/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87462003,"identity":"e2ff3374-71bd-4f02-b308-7f66dc74eb61","added_by":"auto","created_at":"2025-07-24 06:22:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1051647,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6644068/v1/2b446937-f28b-489d-b13b-2e81dad15350.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Application of trauma informed care for childbirth trauma: The clinical profile of Australian patients accessing a tertiary antenatal intervention","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSignificant public interest and global attention has been directed towards the importance of positive childbirth experience (WHO; 1), with adverse implications of a traumatic childbirth on both the mother and infant (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Whilst prevalence estimates range from 4.7% (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) to 44% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), without effective and routine assessment capable of identifying women with childbirth trauma, estimates are not likely to capture the extent of occurrence (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), or the likelihood of childbirth trauma arising in clinical practice. Consequently, understanding childbirth trauma, and how it may present diagnostically, is necessary to support maternal mental health, fetal development, and effective delivery of maternity care. This paper is designed to present a comprehensive description of a cohort of women that have received a psychological antenatal intervention for childbirth trauma in the form of childbirth plans (i.e., Sensitive Care Birth Plans; SCBPs) at a women’s hospital in Australia.\u003c/p\u003e \u003cp\u003eAlthough definitions of childbirth trauma may vary, it is based on the subjective experience of the individual (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), rather than external criteria or obstetric complexity. Childbirth trauma includes women diagnosed with posttraumatic stress disorder (PTSD) following childbirth, as well as those that experience subclinical or posttraumatic stress (PTS) or posttraumatic stress symptoms (PTSS). PTS or PTSS includes the diagnostic symptoms of PTSD but differs in the intensity, duration and impact on daily life. Diagnosis of PTSD requires symptom duration of more than one month, whereas PTS or PTSS is recognised as those symptoms directly after a traumatic event (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; DSM-V-TR; 8).\u003c/p\u003e \u003cp\u003ePTSD is a trauma and stressor-related disorder in the DSM-V-TR (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) that involves the experience of a perceived threat to one’s own life or the life of another. For childbirth related PTSD, this may be characterised by nightmares or flashbacks about a previous childbirth, physiological responses to exposure to stimuli around pregnancy; childbirth or the birth, which can include being at the hospital; attending antenatal appointments; medical examinations; or reading about childbirth (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Avoidance may present with difficulty answering questions about previous childbirth experience or the upcoming birth, with the possibility of medical care avoidance where women struggle to attend antenatal appointments because of childbirth related PTSD.\u003c/p\u003e \u003cp\u003eA challenge for maternity care providers identifying women more likely to experience childbirth related PTSD, is the risk to life may not correspond to the subjective experience of the woman (e.g., \"I will not get up again\"; \"will my baby live\"; 10). This means women may not be identified when the childbirth trauma occurs or in subsequent pregnancy based on the medical experience or maternal outcomes of the woman. As such, screening for birth-related trauma and the engagement of mental health professionals to provide comprehensive assessment and diagnosis to those women with childbirth related PTSD is required. This approach is observed in multidisciplinary childbirth trauma teams in Norway (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) and Sweden (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). However, whilst 20–48% of women may rate their childbirth experience as traumatic (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), not all of those women will develop PTSD or PTSS post childbirth (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Consequently, it is the identification of those women at increased likelihood of childbirth related PTSD that is central to the application of effective intervention to reduce the prevalence or chronicity of childbirth trauma.\u003c/p\u003e \u003cp\u003eIf untreated, the impact of childbirth trauma can be long lasting for the individual and their family (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). These adverse effects to the woman (i.e., mental health; intimate partner relationship; mother-infant relationship; 16, 17), and her infant (e.g., 18) are well documented (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In the context of maternity care, childbirth trauma may translate to high rates of planned caesarean section preferences in subsequent pregnancies (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), or differences in pain relief during labour or cervical dilation for presentation at hospital, with women reporting increased fear of childbirth less likely to present in active labour (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Childbirth trauma may require high levels of staff support and resources to treat and overcome, with increased filing of patient complaints cases a potential outcome of negative birth experience (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWith increasing presentation of childbirth trauma, higher demand for intervention in hospital and community settings has followed (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), and emerging evidence of effective postnatal psychological intervention to treat PTSD or PTS after childbirth (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). While important, these secondary interventions (i.e., treatment provided after birth and identification of trauma symptoms; 9), do not address the challenges of delivering maternity care to a woman in pregnancy where she presents with childbirth related PTSD or PTS or similarly, experiences of (non-childbirth related) trauma or mental health concerns impacting on the administration of medical care. The alternative is to deliver primary prevention intervention (i.e., antenatal treatment for women with pre-existing factors that may increase the likelihood of childbirth trauma; 9), which is capable of integration into hospital and clinical settings to support delivery of care to the woman and optimal maternal and infant outcomes. Yet current evidence for primary prevention intervention for childbirth trauma is far more limited (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23 CR24\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e–\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) with those studies that have been conducted involving low-risk participants, and a lack of examination of women at higher risk of childbirth trauma by reason of complex medical and mental health conditions and subsequent comorbidities.\u003c/p\u003e \u003cp\u003eThe potential for primary prevention intervention for childbirth trauma is facilitated by established risk factors identifiable in pregnancy that may increase the likelihood of childbirth trauma (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Meta-analysis of 50 empirical papers identified these factors as: depression, PTSD history, childbirth fear, pregnancy complications, lack of support, dissociation, obstetric intervention, poor coping skills, and stress exposure (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Also identified is unplanned caesarean section (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), operative vaginal birth (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), method of placenta removal (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), pain intensity (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), and lack of concordance between desired and actual type of birth (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). With knowledge of these factors, it follows that primary prevention intervention in pregnancy may be applied to treat women and reduce the likelihood of childbirth trauma postnatally, or at least, mitigate the chronicity of childbirth trauma symptoms. However, recent systematic review of available antenatal interventions for childbirth trauma identified only 14 studies, and did not identify any reports of existing interventions implemented with women with mental illness or PTSD history (under review; 32).\u003c/p\u003e \u003cp\u003eDespite limited evidence based primary prevention interventions for childbirth trauma, the existing studies indicate preliminary efficacy (under review; 32). Available interventions include: cognitive behavioural therapy (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e); eye movement desensitisation and reprocessing (EMDR; 34, 35); childbirth plans (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e); haptotherapy and hypnosis (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e); trauma-informed care (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e); and antenatal education (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Treatment effectiveness of childbirth plans shows increased rates of positive childbirth experience, childbirth control and mastery, participation, and self-efficacy (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Reduced PTSD symptoms are noted from antenatal education (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Despite the evidence offered by these studies, to the best of our knowledge, the effectiveness of antenatal intervention for childbirth trauma on a sample of women with mental health diagnoses has yet to be tested.\u003c/p\u003e \u003cp\u003eOne such primary prevention intervention currently implemented with individuals with mental health diagnoses identified in pregnancy as at risk of childbirth trauma, is at the (blinded for peer review) Women and Newborn Health Service (WNHS) (service) at King Edward Memorial Hospital (KEMH) (hospital) in Western Australia (WA) (hospital site location). Sensitive Care Birth Plans (SCBPs) are an enduring document developed during a collaborative process between clinician and woman with individualised and unique strategies to facilitate trauma-informed care. The SCBP is cost effective and efficient, with delivery provided in one psychotherapy session (which may be in the context of longer-term psychotherapy), and no additional training for the mental health clinician. Whilst this intervention is implemented clinically, little is known about the clinical profile of the women receiving the intervention.\u003c/p\u003e\n\u003ch3\u003eOur study\u003c/h3\u003e\n\u003cp\u003eThis study aims to describe the common characteristics of women accessing SCBPs at one tertiary hospital site WNHS, WA (service). This will establish a clinical profile for the application of SCBPs and potentially facilitate antenatal identification of women who may be at risk of childbirth trauma. The SCBP intervention has the potential to provide a model for other services of equitable, cost-effective, and evidence-based antenatal intervention that can enhance maternal and infant outcomes in the context of childbirth and the postpartum.\u003c/p\u003e \u003cp\u003eIn this paper, we address the following three objectives:\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo identify the sociodemographic and mental health characteristics of the patients utilising the sensitive birth care plans (SCBPs) at WNHS (service) during the period of January 2022 to December 2022.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo identify the service use characteristics of the women utilising the SCBPs during the period of January 2022 to December 2022.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eOf the women utilising the SCBPs in the service during the period of January 2022 to December 2022, to assess birth and neonatal outcomes.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003cp\u003e\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Method","content":"\u003ch2\u003eDesign and Sample\u003c/h2\u003e\u003cp\u003eFor this retrospective medical file review, a cohort of 126 women were included, which is the total number of SCBPs that were provided in the context of antenatal treatment between 1 January 2022 and 31 December 2022 at WNHS, Mental Health Service: Outpatient and Consultation Liaison (service blinded for peer review). The cohort were identified by a review of all Sensitive Care Plans provided by researchers in the team who are also treating clinicians at the service (J.C., K.D., K.K.M., C.B., and D.C). All data extraction regarding patients identified from their SCBPs involved review of physical medical files, with treatment occurring before the introduction of digital medical records at the service. This study has Human Research Ethics Committee (HREC) approval from the Department of Health Western Australia (RGS0000006343), and cross-institutional approval from Murdoch University’s HREC (2024/005).\u003c/p\u003e\n\u003ch3\u003eInclusion and Exclusion Criteria\u003c/h3\u003e\n\u003cp\u003eInclusion criteria for the retrospective file review included: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) past or current patients of the WNHS; (service) (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) SCBPs dated between 1 January 2022 and 31 December 2022; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) the SCBP was delivered in the context of antenatal intervention for childbirth trauma and, (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) the SCBP was provided during psychological treatment at the WNHS (service). The date for selection of the files was nominated based on the introduction of documentation by WNHS (service) at that time indicating integration of the intervention within the service. Exclusion criteria included: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) women who had an SCBP for purposes other than the prevention of birth trauma, PTSD, or trauma symptoms post childbirth; and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) women whose perinatal services and/or birth did not take place at KEMH (service).\u003c/p\u003e\n\u003ch3\u003eProcedure and Patient Data\u003c/h3\u003e\n\u003cp\u003eThe retrospective file review of eligible participants\u0026rsquo; medical files occurred between March 2023 and April 2023. The review was conducted by researchers J.C., K.D., K.K.M., C.W., C.B. and D.C., with any disagreement regarding data extraction resolved following consultation with researcher S.W. There were no outstanding disagreements. Data was extracted on an agreed list of maternal and infant variables. The variable extraction list was finalised following consensus amongst researchers (J.C., K.D., K.K.M., C.W., C.B., D.C, S.W.) and the HREC. Data from the files was entered into a WA Health (service)-hosted REDCap project accessible only to investigators. The data extracted included characteristics to describe participants\u0026rsquo; sociodemographic, mental health, experiences of trauma, health service use, and birthand neonatal outcomes.\u003c/p\u003e\n\u003ch3\u003eSociodemographic Characteristics\u003c/h3\u003e\n\u003cp\u003eSociodemographic data extracted included participant age at first booking, educational attainment, parity, and substance use.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eMental Health\u003c/h2\u003e \u003cp\u003eMental health data included a participant-reported history of mental health diagnosis and prior admission to an inpatient mental health service. A current mental health diagnosis, consistent with the \u003cem\u003eInternational Classification of Diseases (ICD-10)\u003c/em\u003e were extracted from participant files. Data for mental health symptoms and psychosocial risk screeners were also extracted.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMaternal depressive and anxious symptoms.\u003c/b\u003e The EPDS (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) is incorporated as part of routine antenatal screening for depression at KEMH (service) for all women at two antenatal visits. The EPDS is a ten-item self-report measure and response scale of 0 to 3. Responses are summed, with a total score ranging from 0 to 30 and higher scores indicative of more depressive symptoms. Three items can be scored separately to assess anxiety, with a sum score ranging 0 through 9 (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). The EPDS has been validated for application with Australian postpartum women (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Women who score 13 or higher are considered as being at an elevated risk of having a depressive disorder, which has been recommended empirically due to high sensitivity and specificity with respect to accuracy in identifying clinical cases.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePsychosocial risk factors.\u003c/b\u003e The ANRQ (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) is incorporated into routine antenatal screening of psychosocial risk at KEMH(service). The ANRQ is a 14-item self-report scale designed to measure psychosocial risk factors in pregnancy, including mental health history, trauma history, social supports, and current stressor exposures. Responses are summed with a total score ranging between 5 and 67, with higher scores denoting higher psychosocial risk. The ANRQ has been validated for routine antenatal screening in maternity clinical settings, with a score of 23 used to indicate increased psychosocial risk (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTrauma\u003c/h3\u003e\n\u003cp\u003eTraumatic experiences data extracted included history of and forms of childhood trauma (including sexual abuse, and physical and emotional abuse and neglect) and other trauma experienced as an adult (including sexual and/or physical trauma, emotional abuse, emotional and physical neglect, and coercive control). Data was also extracted for prior pregnancy loss (i.e., miscarriage; abortion; fetal loss or stillbirth or neonatal death), and prior birth trauma.\u003c/p\u003e\n\u003ch3\u003eHealth Service Use\u003c/h3\u003e\n\u003cp\u003eHealth service data extracted included the clinic providing antenatal care, the number of antenatal hospital admissions and length of stay for each, length of postnatal admission following birth, and the number of psychotherapy sessions, both antenatally and postnatally, scheduled and attended at the Mental Health Service at KEMH (service).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eBirth and Neonatal Outcomes\u003c/h2\u003e \u003cp\u003eBirth and neonatal outcome data extracted included induction and augmentation, mode of birth, gestation at birth, and admission to a special care nursery or neonatal intensive care nursery (SCN/NICU).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analyses\u003c/h2\u003e \u003cp\u003eAll statistical analyses were performed using Stata 16.0 (StataCorp, 2019). Demographic data will be analysed using descriptive statistics. For all objectives, data were analysed primarily using descriptive statistics, presented as frequencies (i.e., \u003cem\u003en\u003c/em\u003e and %) or measures of central tendency (i.e., \u003cem\u003eM\u003c/em\u003e and \u003cem\u003eSD\u003c/em\u003e for normally distributed numerical data, or \u003cem\u003eMdn\u003c/em\u003e and \u003cem\u003eIQR\u003c/em\u003e for non-normally distributed numerical data). Missing data is a common issue with medical record data extraction; as such, we report missing data for each variable and clearly indicate where reported percentages are adjusted for the number of cases with missing data in the denominator (i.e., valid percent). Where possible, a comparison between the descriptive statistic for the SCBP cohort is compared to all women giving birth and infants born at KEMH (service) during the study period, 1 January 2022 to 31 December 2022 (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5,401, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5,580 babies).\u003c/p\u003e \u003cp\u003eFor Objective 3 specifically, birth and neonatal outcomes of the SCBP cohort are compared to all births at KEMH (service) during the study period. The prevalence of outcomes will be reported for the two samples and compared inferentially using Risk Ratios (RR) with associated 95% confidence intervals (95% CIs) and exact \u003cem\u003ep\u003c/em\u003e-values. Statistical significance for \u003cem\u003eRR\u003c/em\u003es is assessed at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic Profile of Patients with a SCBP\u003c/h2\u003e \u003cp\u003eWomen who received the SCBP intervention during their antenatal care at KEMH (service) were an average of 30.34 years of age (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7.04), ranging between 14.1 years and 44.4 years of age, which was slightly younger than the average of all pregnant women at KEMH (service) during the study period (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;32.16 years, \u003cem\u003emin\u003c/em\u003e\u0026thinsp;=\u0026thinsp;14 years, \u003cem\u003emax\u003c/em\u003e\u0026thinsp;=\u0026thinsp;49 years). There were significantly more participants (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;11/126, 8.73%) aged less than 18 years in the SCBP cohort compared to all pregnant women at KEMH (service) during the study period (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;64/5,401, 1.18%; \u003cem\u003eχ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e[1]\u0026thinsp;=\u0026thinsp;51.83, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents other select socioeconomic characteristics of the SCBP cohort. A university degree was the most common level of educational attainment amongst participants (36.1%); however, educational attainment was not identified for 14.3% of participants. Substance use was identified in almost one-fifth of women (18.8%) and a similar proportion were nulliparous (19.8%). For multiparous women, gravidity ranged between two and 14 pregnancies (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3, \u003cem\u003eIQR\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2\u0026ndash;4).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eMental Health Profile of Patients with a SCBP\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents mental health characteristics of the SCBP cohort at KEMH(service). More than three-quarters of participants (78.6%) were identified as having a history of mental health difficulties, with 14 (11.7%) having a history of inpatient admission for mental health difficulties. A current mental health diagnosis was not identified during the review of 24 participant files (19.1%). For the 102 participants with an \u003cem\u003eICD-10\u003c/em\u003e block-level mental and behavioural disorder recorded in their file, neurotic, stress-related and somatoform disorders (F40\u0026ndash;F48) were the most prevalent diagnoses (85.3%). Within this category (F40\u0026ndash;48), reaction to severe stress, and adjustment disorders (F43) were the most common (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;37, 36.3%), with PTSD (n\u0026thinsp;=\u0026thinsp;24, 23.5%) the most common F43 diagnosis.\u003c/p\u003e \u003cp\u003eThe median EPDS score recorded for 108 of 126 patients (85.7%), administered during the first appointment, was 10 (IQR\u0026thinsp;=\u0026thinsp;5\u0026ndash;15) and ranged between 0 and 26. For the anxiety subscale of the EPDS, the median was 5 (IQR\u0026thinsp;=\u0026thinsp;3\u0026ndash;7), ranging between 0 and 9. The median ANRQ score recorded for 79 of 126 participants (62.7%), administered during the first appointment was 31 (\u003cem\u003eIQR\u003c/em\u003e\u0026thinsp;=\u0026thinsp;23\u0026ndash;40) and ranged between 7 and 57. Using the cut off score of 23 or above, 76.0% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;60/79) of participants who completed an ANRQ were identified to be at psychosocial risk. In contrast, 36.1% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;39/108) of participants who completed EPDS scores 13 or above and were identified as having an elevated risk of depression. Of the 73 participants who completed both the EPDS and the ANRQ, all 25 (34.3%) identified by the EPDS as having an elevated risk of depression were also identified by the ANRQ as being at increased psychosocial risk; however, there were 30 (41.1%) identified at increased psychosocial risk by the ANRQ but not at increased risk of depression by the EPDS alone.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTrauma History Profile of Patients with a SCBP\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents experiences of childhood and current traumas, prior pregnancy loss and past birth trauma for the SCBP cohort. Extracting data from participant files for the childhood and current traumatic experiences variables proved difficult, with 23.8% and 30.1% missing data, respectively. However, of those with data, 63.5% were identified as having experienced trauma during their childhood and 63.2% were identified as having experienced trauma during adulthood. Almost half of multiparous participants (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;101) had experienced prior pregnancy loss (44.1%), with prior miscarriage being the most prevalent experience of loss (30.6%). Further, 62.4% of multiparous women were identified as having reported prior birth trauma; however, less than half of the women who reported prior birth trauma reported receiving treatment specifically for their birth trauma experience (n\u0026thinsp;=\u0026thinsp;28/63, 43.8%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eHealth Service Use Profile of Patients with a SCBP\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e displays service use characteristics for the SCBP cohort. Women in the SCBP cohort were managed mostly by obstetric led antenatal clinics (20.2%) and a maternal-fetal medicine clinic (18.5%) and low and mixed-risk midwifery-led continuity of care through the Family Birthing Centre/Midwifery Group Practice (12.9%). More than one-quarter (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;33/116, 28.4%) of the SCBP cohort had at least one antenatal medical admission prior to their admission for birthing (i.e., \u0026ge; 2 antenatal medical admission). The collective number of antenatal medical admission days ranged between 1 and 36, with a median of 2 days (\u003cem\u003eIQR\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1\u0026ndash;15). The majority of the SCBP cohort were in hospital for between one- and five-days following birth (81.3%). The number of Mental Health Service appointments booked and attended by SCBP cohort women varied substantially; however, the medians for appointments booked (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;10) and attended (\u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9) were similar. The majority of SCBP cohort women attended 80% or more of their booked appointments (n\u0026thinsp;=\u0026thinsp;106/125, 84.8%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eBirth and Neonatal Outcomes of Patients with a SCBP\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e displays birth and neonatal outcomes for participants in the SCBP cohort at KEMH (service), compared to all women and babies at KEMH (service) during 2022. Across the limited data we collected, birth and neonatal outcomes were similar for the SCBP baseline cohort compared to all pregnancies at KEMH (service) during 2022, except for SCN/NICU admissions of infants. Infants born to women who accessed the SCBP intervention were at a 79% significantly greater risk of admission to SCN/NICU compared to all infants born at KEMH (a tertiary referral maternity hospital that accepts referrals for complex pregnancies for the state) during 2022 (\u003cem\u003eOR\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.79 [\u003cem\u003e95% CI\u003c/em\u003e: 1.42, 2.26], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study is the first to identify the profile of Australian women who accessed an antenatal intervention for childbirth trauma at a tertiary perinatal service. In the cohort of 126, the proportion of adolescent pregnancies was higher relative to all women birthing at the service in the same year, with substance use identified in one-fifth of the cohort. Clinically, neurotic, stress-related and somatoform disorders, including PTSD, were the most prevalent psychiatric disorders, identified as present in 85 percent of the sample. In addition, almost all women had at least one diagnosed physical condition. Routine screening measures showed elevated psychosocial risk in three-quarters of the cohort, compared to an elevated risk of depression in approximately one-third of the women. Two-thirds of the cohort reported childhood or adult trauma, with another two-thirds of multiparous women reporting prior birth trauma and half experiencing prior pregnancy loss. Service-related characteristics revealed that more than one-quarter of the sample had at least one antenatal medical admission prior to admission for birthing. Treatment engagement was generally high; with over 80 percent of women attending all booked psychological appointments. Infants of women in this sample were at higher risk of admission to the SCN/NICU compared to all infants born at the service in the same year. Although elective caesarean section rates were elevated relative to all birth at the service in the same year, this trend did not reach statistical significance. These identified characteristics, often presenting as a complex interaction for many women, represent risk factors that are identifiable antenatally and capable of being targeted through intervention before childbirth to enhance maternal and infant outcomes.\u003c/p\u003e \u003cp\u003ePrior traumatic experience was a key characteristic of the cohort with prevalence rates of approximately 60% for trauma in childhood, adulthood, and childbirth. Of the five domains of childhood trauma, childhood sexual abuse was most prevalent, identified in more than half the cohort, with one-quarter reporting childhood emotional abuse. Childhood trauma is well established as a risk factor for mental health disorders (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), with the neurobiological stress regulation system more vulnerable at sensitive and critical periods following early life exposure to adversity and trauma (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). Recently, Porthan et al. (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e) found that childhood emotional abuse and neglect along with a higher total burden of childhood trauma, were associated with an increased fear of childbirth. Whilst this highlights the increased likelihood of fear of childbirth in the context of childhood trauma, it also represents a current challenge for the childbirth trauma literature with the outcome of fear of childbirth frequently applied to measure the effectiveness of childbirth trauma interventions (e.g., 22, 34, 36). Yet a sample of women with fear of childbirth is not representative of women with PTSD post-childbirth or subthreshold PTSD symptoms. In addition, rates of prior childbirth trauma were elevated in our sample, with two-thirds of multiparous women identified as having a previously traumatic birth, compared to international estimates ranging between one and 44 percent (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Collectively, these findings describe a population characterised by significant, complex past and current trauma, who are at risk of re-traumatisation during childbirth. This demonstrates the necessity of early identification of antenatal patients with prior trauma experience so that trauma-informed care can be facilitated within maternity services.\u003c/p\u003e \u003cp\u003eThe prevalence of prior pregnancy loss in this cohort highlights the salience of this experience for subsequent pregnancies (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). This finding also indicates the increased likelihood of childbirth trauma where pregnancy loss has been identified, and the need for healthcare professionals to be aware of prior pregnancy loss and the possible impact on other pregnancies, whether it is miscarriage, stillbirth, or abortion history. Almost half the women in this cohort reported a prior pregnancy loss. Although the prevalence of miscarriage in our sample was similar to what has been reported in community samples (24% verses 19%) (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e), the prevalence of both abortion (i.e., 6.5% verses 1.73%; 52) and stillbirth (i.e., 7.3% verses 0.72%; 53) were markedly higher in our sample compared to Australian population estimates. Outside of these findings, we are not aware of any other studies that have previously identified pregnancy loss a risk factor for childbirth trauma (e.g., 27). Whilst more recently we can see acknowledgement of the need for trauma-informed care in the context of perinatal loss (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e), there has been a documented failure to recognise the long-lasting emotional effect of perinatal loss on women, with maternal identity not consistently acknowledged for women after stillbirth (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e), and a lack of perceived social support increasing feelings of isolation and grief (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). A recent review on pregnancy loss and perinatal mental health (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e) highlighted the variation in the individual response to pregnancy loss. Factors including cultural and religious beliefs, race, and age, as well as the response of medical providers were identified as influencing the likelihood and chronicity of the psychological impact of pregnancy loss. That said, pregnancy loss is an identifiable antenatal factor and information that is consistently available in medical records; thus, improving the awareness of this as a potential risk for childbirth trauma may facilitate increased access to trauma-informed care for those women in subsequent pregnancies.\u003c/p\u003e \u003cp\u003eThe routine completion and documentation of screening measures during antenatal care is a critical step for the identification of women at risk of childbirth trauma who may benefit from preventative psychological intervention during pregnancy. Documentation of the EPDS and the ANRQ was not consistent in this cohort, with almost 15% not having an EPDS recorded and almost 40% not having an ANRQ recorded; this is despite both being recommended for use in combination as screening measures in Australian national guidelines (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e). For those women where both screening measures were recorded, over 40% identified as having an elevated psychosocial risk on the ANRQ did not have scores indicating elevated risk of depression on the EPDS. This differential highlights the limitations of relying exclusively on a screening tool for depression to screen for what is a broad and diverse spectrum of illness and experience. The EPDS has become widely relied upon as the only measure of depression (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e), despite recommendations for its application to not to be relied upon in the absence of other screening tools (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e). With nearly half of the cohort missing a completed ANRQ, a consideration of the barriers to screening for psychosocial adversity is required. What is clear from these results is that antenatal psychosocial screening is important for this population and that screening for depression alone will result in many women at risk of childbirth trauma falling through service gaps. These findings are a mandate for the review and development of effective antenatal screening to identify women who are at risk of childbirth trauma.\u003c/p\u003e \u003cp\u003eHigh levels of service demand are represented in this sample for the woman and the infant. Compared to Australian population estimates, infants in this cohort were more than two times more likely to be admitted to the SCN or NICU (i.e., 37.4% verses 13.15%, respectively; 61). When compared to all infants born at the service in the same year, infants born to women in the cohort were nearly 80 percent more likely to be admitted to an SCN/NICU. This increased risk remained statistically significant even after removing women attending the service\u0026rsquo;s complex antenatal care clinics (i.e., preterm, complex medical care, and adolescent). Research has grappled with the impact of the NICU experience for maternal mental health with higher rates of depression and anxiety (\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e), as well as clinical PTSD and PTSS (\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e). With high rates of trauma past and current, together with the increased likelihood of exposure to another stressful event such as an infant admission to the NICU, these findings highlight the potential for this cohort to experience multiple traumas across the perinatal period. Given evidence that exposure to multiple types of adversity is a stronger predictor of psychopathology then severe or chronic single traumatic experiences (\u003cspan additionalcitationids=\"CR67\" citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e), the vulnerability of women accessing antenatal intervention for childbirth trauma is again demonstrated.\u003c/p\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eA challenge of this study involved the missing data in participant files, which may more widely indicate that information about women at risk of childbirth trauma is not consistently collected during antenatal screening. Consultation with the health care clinicians that provide the screening needs to occur to identify the barriers to administration, with focus group consultation a next step. This is particularly important in considering equitable access to supports and services, with referral of women with high risk of childbirth trauma potentially less likely if screening for risk factors is not conducted.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study aimed to describe the clinical cohort of women accessing a primary prevention intervention for childbirth trauma at a tertiary women’s hospital in Western Australia (service location). Maternal and infant characteristics highlighted the complex interaction of risk factors for women accessing childbirth trauma intervention including stress-related, anxiety, and PTSD mental health diagnoses, medical comorbidity, childhood and adult trauma, pregnancy loss, and substance use. The rates of service use required for this cohort is also evident in the increased likelihood of NICU admission as well as the trending higher rates of planned elective caesarean section. Different outcomes may be achieved in reducing the chronicity and likelihood of occurrence of childbirth trauma where antenatal risk factors are identified, and antenatal intervention can be provided. This requires a multidisciplinary approach, like those modelled in Sweden and Norway, where screening identifies higher rates of childbirth fear for referral to antenatal childbirth trauma or fear of childbirth teams, capable of providing treatment to enhance the experience of childbirth as well as facilitating optimal medical outcomes for both the woman and child.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has Human Research Ethics Committee (HREC) approval dated 12 December 2023 from the Department of Health Western Australia\u0026nbsp;(RGS0000006343),\u0026nbsp;and cross-institutional approval from Murdoch University\u0026rsquo;s HREC dated 1 February 2024 (2024/005). The data analysed during the current study did not involve consent to participate because it was extracted from medical records as per ethics and hospital approvals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data contained in this manuscript is deidentified and anonymous. No individual identifying information can be applied.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data analysed during the current study is not publicly available because it was extracted from medical records and as per ethics, and hospital approvals, the data is not available for sharing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOpen access funding was provided by the Women and Newborn Health Service, King Edward Memorial Hospital, Subiaco, Western Australia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKKM: Conceptualisation; methodology; data collection; analysing and interpreting results; writing of manuscript; reviewing of manuscript; supervision.\u003c/p\u003e\n\u003cp\u003eCFG: Analysing and interpreting data and results; writing \u0026ndash; review and editing.\u003c/p\u003e\n\u003cp\u003eSJW: Conceptualisation; methodology; analysing data; interpreting results; writing of manuscript; supervision.\u003c/p\u003e\n\u003cp\u003eDBC: Conceptualisation; methodology; data collection; interpreting results; writing \u0026ndash; review and editing.\u003c/p\u003e\n\u003cp\u003eKD: Conceptualisation; data collection; writing \u0026ndash; review and editing.\u003c/p\u003e\n\u003cp\u003eJC: Conceptualisation; data collection; writing \u0026ndash; review and editing.\u003c/p\u003e\n\u003cp\u003eCB: Conceptualisation; data collection; writing \u0026ndash; review and editing.\u003c/p\u003e\n\u003cp\u003eCW: Data collection.\u003c/p\u003e\n\u003cp\u003eZB: Data interpretation; writing \u0026ndash; review and editing.\u003c/p\u003e\n\u003cp\u003eSWW: Data interpretation; writing \u0026ndash; review and editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to acknowledge the support of the Women and Newborn Health Service (WNHS) of Western Australia in conducting this research and supporting the establishment of the Childbirth Trauma Research Project. We also want to acknowledge the support of the Directors of WNHS in the publication of these meaningful findings, as well as the clinicians and their tireless efforts to support women during this critical time. And most importantly, we acknowledge all individuals who have birthed a baby \u0026ndash; this research is for you.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO WHO. WHO recommendations: Intrapartum care for a positive childbirth experience. Geneva; 2018 2018.\u003c/li\u003e\n\u003cli\u003eDekel S, Stuebe C, Dishy G. Childbirth induced posttraumatic stress syndrome: a systematic review of prevalence and risk factors. Frontiers in psychology. 2017;8:560.\u003c/li\u003e\n\u003cli\u003ePidd D, Newton M, Wilson I, East C. Optimising maternity care for a subsequent pregnancy after a psychologically traumatic birth: A scoping review. 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The aetiology of post-traumatic stress following childbirth: a meta-analysis and theoretical framework. Psychological medicine. 2016;46(6):1121-34.\u003c/li\u003e\n\u003cli\u003eViirman F, Hesselman S, Wikstr\u0026ouml;m A-K, Svanberg AS, Skalkidou A, Poromaa IS, Wikman A. Negative childbirth experience\u0026ndash;what matters most? a register-based study of risk factors in three time periods during pregnancy. Sexual \u0026amp; Reproductive Healthcare. 2022;34:100779.\u003c/li\u003e\n\u003cli\u003eWaller R, Kornfield SL, White LK, Chaiyachati BH, Barzilay R, Njoroge W, et al. Clinician-reported childbirth outcomes, patient-reported childbirth trauma, and risk for postpartum depression. Archives of women\u0026apos;s mental health. 2022;25(5):985-93.\u003c/li\u003e\n\u003cli\u003eMousavi S, Nourizadeh R, Mokhtari F, Hakimi S, Babapour J, Mousavi S. Determinants of Postpartum Post-traumatic Stress Disorder: A Cross-Sectional Study. Crescent Journal of Medical \u0026amp; Biological Sciences. 2020;7(2).\u003c/li\u003e\n\u003cli\u003eRyding E, Wijma B, Wijma K, Rydhstr\u0026ouml;m H. Fear of childbirth during pregnancy may increase the risk of emergency cesarean section. Acta obstetricia et gynecologica Scandinavica. 1998;77(5):542-7.\u003c/li\u003e\n\u003cli\u003eMacMillan KK, Greenhalgh, C.F., Cleary, D.B., Cahill, J., Dedman, K., Bright, C., \u0026amp; Watson, S.J. Childbirth related post-traumatic stress disorder and childbirth trauma: A systematic review of available primary antenatal intervention. Birth Journal (under review). 2025.\u003c/li\u003e\n\u003cli\u003eStevens N, Lillis T, Wagner L, Tirone V, Hobfoll S. A feasibility study of trauma-sensitive obstetric care for low-income, ethno-racial minority pregnant abuse survivors. Journal of Psychosomatic Obstetrics \u0026amp; Gynecology. 2019;40(1):66-74.\u003c/li\u003e\n\u003cli\u003eBaas MA, Stramrood CA, Dijksman LM, Vanhommerig JW, de Jongh A, van Pampus MG. How safe is the treatment of pregnant women with fear of childbirth using eye movement desensitization and reprocessing therapy? Obstetric outcomes of a multi‐center randomized controlled trial. Acta Obstetricia et Gynecologica Scandinavica. 2023;102(11):1575-85.\u003c/li\u003e\n\u003cli\u003eBaas M, van Pampus M, Stramrood C, Dijksman L, Vanhommerig J, de Jongh A. Treatment of Pregnant Women With Fear of Childbirth Using EMDR Therapy: Results of a Multi-Center Randomized Controlled Trial. Frontiers in psychiatry. 2022;12:798249.\u003c/li\u003e\n\u003cli\u003eKlabbers GA, Wijma K, Paarlberg KM, Emons WH, Vingerhoets AJ. Haptotherapy as a new intervention for treating fear of childbirth: a randomized controlled trial. Journal of Psychosomatic Obstetrics \u0026amp; Gynecology. 2019;40(1):38-47.\u003c/li\u003e\n\u003cli\u003eWerner A, Uldbjerg N, Zachariae R, Nohr EA. Effect of self‐hypnosis on duration of labor and maternal and neonatal outcomes: a randomized controlled trial. Acta obstetricia et gynecologica Scandinavica. 2013;92(7):816-23.\u003c/li\u003e\n\u003cli\u003eMcKenzie-McHarg K, Crockett M, Olander EK, Ayers S. Think pink! A sticker alert system for psychological distress or vulnerability during pregnancy. British Journal of Midwifery. 2014;22(8):590-5.\u003c/li\u003e\n\u003cli\u003eToohill J, Fenwick J, Gamble J, Creedy DK, Buist A, Turkstra E, Ryding EL. A randomized controlled trial of a psycho‐education intervention by midwives in reducing childbirth fear in pregnant women. Birth. 2014;41(4):384-94.\u003c/li\u003e\n\u003cli\u003eCox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. The British journal of psychiatry. 1987;150(6):782-6.\u003c/li\u003e\n\u003cli\u003eJomeen J, Martin CR. Confirmation of an occluded anxiety component within the Edinburgh Postnatal Depression Scale (EPDS) during early pregnancy. Journal of Reproductive and infant psychology. 2005;23(2):143-54.\u003c/li\u003e\n\u003cli\u003eBoyce P, Stubbs J, Todd A. The Edinburgh postnatal depression scale: validation for an Australian sample. Australian \u0026amp; New Zealand Journal of Psychiatry. 1993;27(3):472-6.\u003c/li\u003e\n\u003cli\u003eAustin M-P, Colton J, Priest S, Reilly N, Hadzi-Pavlovic D. The antenatal risk questionnaire (ANRQ): acceptability and use for psychosocial risk assessment in the maternity setting. Women and Birth. 2013;26(1):17-25.\u003c/li\u003e\n\u003cli\u003eAustin MPV, Middleton PF, Highet NJ. Australian mental health reform for perinatal care. 2011. p. 112-3.\u003c/li\u003e\n\u003cli\u003eCarr CP, Martins CMS, Stingel AM, Lemgruber VB, Juruena MF. The role of early life stress in adult psychiatric disorders: a systematic review according to childhood trauma subtypes. The Journal of nervous and mental disease. 2013;201(12):1007-20.\u003c/li\u003e\n\u003cli\u003eNemeroff CB. Neurobiological consequences of childhood trauma. Journal of clinical psychiatry. 2004;65:18-28.\u003c/li\u003e\n\u003cli\u003eCampbell TL. Screening for adverse childhood experiences (ACEs) in primary care: a cautionary note. Jama. 2020;323(23):2379-80.\u003c/li\u003e\n\u003cli\u003ePorthan E, Lindberg M, H\u0026auml;rk\u0026ouml;nen J, Scheinin NM, Karlsson L, Karlsson H, Ekholm E. Childhood trauma and fear of childbirth: findings from a birth cohort study. Archives of women\u0026apos;s mental health. 2023;26(4):523-9.\u003c/li\u003e\n\u003cli\u003eHunter A, Tussis L, MacBeth A. The presence of anxiety, depression and stress in women and their partners during pregnancies following perinatal loss: A meta-analysis. Journal of Affective Disorders. 2017;223:153-64.\u003c/li\u003e\n\u003cli\u003eThomas S, Stephens L, Mills TA, Hughes C, Kerby A, Smith DM, Heazell AE. Measures of anxiety, depression and stress in the antenatal and perinatal period following a stillbirth or neonatal death: a multicentre cohort study. BMC pregnancy and childbirth. 2021;21:1-9.\u003c/li\u003e\n\u003cli\u003eMagnus MC, Hockey RL, H\u0026aring;berg SE, Mishra GD. Pre-pregnancy lifestyle characteristics and risk of miscarriage: the Australian Longitudinal Study on Women\u0026rsquo;s Health. BMC pregnancy and childbirth. 2022;22(1):169.\u003c/li\u003e\n\u003cli\u003eKeogh LA, Gurrin LC, Moore P. Estimating the abortion rate in Australia from National Hospital Morbidity and Pharmaceutical benefits Scheme data. Medical journal of Australia. 2021;215(8):375-6.\u003c/li\u003e\n\u003cli\u003eWelfare AIoHa. Australia\u0026apos;s mothers and babies. Canberra: Australian Government; 2023.\u003c/li\u003e\n\u003cli\u003eBenton M, Wittkowski A, Edge D, Reid H, Quigley T, Sheikh Z, Smith DM. Best practice recommendations for the integration of trauma-informed approaches in maternal mental health care within the context of perinatal trauma and loss: A systematic review of current guidance. Midwifery. 2024:103949.\u003c/li\u003e\n\u003cli\u003eBurden C, Bradley S, Storey C, Ellis A, Heazell AE, Downe S, et al. From grief, guilt pain and stigma to hope and pride\u0026ndash;a systematic review and meta-analysis of mixed-method research of the psychosocial impact of stillbirth. BMC pregnancy and childbirth. 2016;16:1-12.\u003c/li\u003e\n\u003cli\u003eRowlands IJ, Lee C. \u0026lsquo;The silence was deafening\u0026rsquo;: social and health service support after miscarriage. Journal of reproductive and infant psychology. 2010;28(3):274-86.\u003c/li\u003e\n\u003cli\u003eCuenca D. Pregnancy loss: Consequences for mental health. Frontiers in global women\u0026apos;s health. 2023;3:1032212.\u003c/li\u003e\n\u003cli\u003eAustin M-P, Kingston D. Psychosocial assessment and depression screening in the perinatal period: benefits, challenges and implementation. Joint care of parents and infants in perinatal psychiatry: Springer; 2016. p. 167-95.\u003c/li\u003e\n\u003cli\u003eGalbally M, Watson SJ, Boyce P, Howard L, Herrman H. Perinatal depression: The use of the Edinburgh Postnatal Depression Scale to derive clinical subtypes. Australian \u0026amp; New Zealand Journal of Psychiatry. 2024;58(1):37-48.\u003c/li\u003e\n\u003cli\u003eCox J. Thirty years with the Edinburgh Postnatal Depression Scale: voices from the past and recommendations for the future. The British Journal of Psychiatry. 2019;214(3):127-9.\u003c/li\u003e\n\u003cli\u003eHealth GoWADo. Western Australia\u0026apos;s Mothers and Babies Summary Information. 2024.\u003c/li\u003e\n\u003cli\u003eBonacquisti A, Geller PA, Patterson CA. Maternal depression, anxiety, stress, and maternal-infant attachment in the neonatal intensive care unit. Journal of reproductive and infant psychology. 2020;38(3):297-310.\u003c/li\u003e\n\u003cli\u003eCherry AS, Mignogna MR, Roddenberry Vaz A, Hetherington C, McCaffree MA, Anderson MP, Gillaspy SR. The contribution of maternal psychological functioning to infant length of stay in the Neonatal Intensive Care Unit. International Journal of Women\u0026apos;s Health. 2016:233-42.\u003c/li\u003e\n\u003cli\u003eMcKeown L, Burke K, Cobham VE, Kimball H, Foxcroft K, Callaway L. The prevalence of PTSD of mothers and fathers of high-risk infants admitted to NICU: a systematic review. Clinical child and family psychology review. 2023;26(1):33-49.\u003c/li\u003e\n\u003cli\u003eGateau K, Song A, Vanderbilt DL, Gong C, Friedlich P, Kipke M, Lakshmanan A. Maternal post-traumatic stress and depression symptoms and outcomes after NICU discharge in a low-income sample: a cross-sectional study. BMC pregnancy and childbirth. 2021;21:1-10.\u003c/li\u003e\n\u003cli\u003eHamby S, Elm JH, Howell KH, Merrick MT. Recognizing the cumulative burden of childhood adversities transforms science and practice for trauma and resilience. American Psychologist. 2021;76(2):230.\u003c/li\u003e\n\u003cli\u003eHaahr-Pedersen I, Ershadi AE, Hyland P, Hansen M, Perera C, Sheaf G, et al. Polyvictimization and psychopathology among children and adolescents: A systematic review of studies using the Juvenile Victimization Questionnaire. Child Abuse \u0026amp; Neglect. 2020;107:104589.\u003c/li\u003e\n\u003cli\u003eL\u0026auml;tsch DC, Nett JC, H\u0026uuml;mbelin O. Poly-victimization and its relationship with emotional and social adjustment in adolescence: Evidence from a national survey in Switzerland. Psychology of violence. 2017;7(1):1.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"435\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 435px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eSociodemographic characteristics of patients utilising Sensitive Care Birth Plans at KEMH (service) (\u003cem\u003eN\u003c/em\u003e=126)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 350px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 35px;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e%^\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 350px;\"\u003e\n \u003cp\u003e\u003cem\u003eMaternal education (missing=18, 14.3%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 35px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 350px;\"\u003e\n \u003cp\u003eNot known\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 35px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e29.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 350px;\"\u003e\n \u003cp\u003eLeft school prior to Year 12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 35px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e10.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 350px;\"\u003e\n \u003cp\u003eSecondary School Certificate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 35px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 350px;\"\u003e\n \u003cp\u003eTAFE or Certificate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 35px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e15.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 350px;\"\u003e\n \u003cp\u003eUniversity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 35px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e36.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 350px;\"\u003e\n \u003cp\u003eSubstance use (missing = 9, 7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 35px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e18.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 350px;\"\u003e\n \u003cp\u003ePrimiparous\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 35px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e19.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 435px;\"\u003e\n \u003cp\u003e^Valid percent adjusted for missing in the denominator.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"609\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 608px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eMental Health Characteristics of Patients Utilising Sensitive Care Birth Plans at \u0026nbsp;KEMH (service) (\u003cem\u003eN\u003c/em\u003e=126)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 520px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e%^\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 520px;\"\u003e\n \u003cp\u003eMental health history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e78.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 520px;\"\u003e\n \u003cp\u003e\u003cem\u003eHistory of inpatient admission for mental health (missing=6, 4.8%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 520px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e106\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e88.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 520px;\"\u003e\n \u003cp\u003eMBU in last 12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 520px;\"\u003e\n \u003cp\u003eHx of MBU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 520px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 520px;\"\u003e\n \u003cp\u003e\u003cem\u003eCurrent mental health diagnosis (missing=24, 19.1%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 520px;\"\u003e\n \u003cp\u003eF20-F29:\u0026nbsp;Schizophrenia, schizotypal and delusional disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 520px;\"\u003e\n \u003cp\u003eF30-F39:\u0026nbsp;Mood (affective) disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e26.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 520px;\"\u003e\n \u003cp\u003eF40-F48:\u0026nbsp;Neurotic, stress-related and somatoform disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e85.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 520px;\"\u003e\n \u003cp\u003eF50-F59:\u0026nbsp;Behavioural syndromes associated with physiological disturbances and physical factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 520px;\"\u003e\n \u003cp\u003eF60-F69:\u0026nbsp;Disorders of adult personality and behaviour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e8.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 520px;\"\u003e\n \u003cp\u003eF90-F98:\u0026nbsp;Behavioural and emotional disorders with onset usually occurring in childhood and adolescence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 520px;\"\u003e\n \u003cp\u003eZ55-Z65: Persons with potential health hazards related to socioeconomic and psychosocial circumstances\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 520px;\"\u003e\n \u003cp\u003e\u003cem\u003eNumber of mental health diagnoses (missing=24, 19.1%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 520px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e62.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 520px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e28.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 520px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 520px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 520px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 38px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 608px;\"\u003e\n \u003cp\u003e^Valid percent adjusted for missing in the denominator.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"587\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 587px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eTrauma History for Patients Utilising Sensitive Care Birth Plans at KEMH (service) (\u003cem\u003eN\u003c/em\u003e=126)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 514px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e%^\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 514px;\"\u003e\n \u003cp\u003e\u003cem\u003eChildhood trauma (missing=30, 23.8%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cem\u003e61\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e\u003cem\u003e63.5\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 514px;\"\u003e\n \u003cp\u003eSexual abuse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e29.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 514px;\"\u003e\n \u003cp\u003ePhysical abuse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 514px;\"\u003e\n \u003cp\u003eEmotional abuse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 514px;\"\u003e\n \u003cp\u003ePhysical neglect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 514px;\"\u003e\n \u003cp\u003eEmotional neglect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e13.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 514px;\"\u003e\n \u003cp\u003eChildhood trauma, unspecified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e10.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 514px;\"\u003e\n \u003cp\u003e\u003cem\u003eCurrent trauma (missing=39, 30.1%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cem\u003e55\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e\u003cem\u003e63.2\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 514px;\"\u003e\n \u003cp\u003eSexual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e11.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 514px;\"\u003e\n \u003cp\u003ePhysical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 514px;\"\u003e\n \u003cp\u003eEmotional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e28.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 514px;\"\u003e\n \u003cp\u003eCoercive control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 514px;\"\u003e\n \u003cp\u003eUnspecified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e9.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 514px;\"\u003e\n \u003cp\u003e\u003cem\u003ePrior pregnancy loss multiparous women only n=101 (missing=3, 3.0%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e54.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 514px;\"\u003e\n \u003cp\u003eMiscarriage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e30.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 514px;\"\u003e\n \u003cp\u003eFetal death in utero\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e7.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 514px;\"\u003e\n \u003cp\u003eStillbirth without MTOP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e9.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 514px;\"\u003e\n \u003cp\u003e\u003cem\u003eAbortion\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cem\u003e7\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e\u003cem\u003e7.1\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 514px;\"\u003e\n \u003cp\u003eMedical\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e57.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 514px;\"\u003e\n \u003cp\u003eSocial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e14.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 514px;\"\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e14.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 514px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e45.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 514px;\"\u003e\n \u003cp\u003e\u003cem\u003ePrior birth trauma, multiparous women only n=101 (missing=3, 3.0%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cem\u003e63\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e\u003cem\u003e64.3\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 514px;\"\u003e\n \u003cp\u003eTreatment for prior birth trauma, n=63 (missing=5, 7.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 43px;\"\u003e\n \u003cp\u003e48.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 587px;\"\u003e\n \u003cp\u003e^Valid percent adjusted for missing in the denominator.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"616\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 616px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 4.\u0026nbsp;\u003c/strong\u003eHealth Service use characteristics for the\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eSensitive Care Birth Plan Baseline Cohort (\u003cem\u003eN\u0026nbsp;\u003c/em\u003e= 126)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003e\u003cem\u003eAntenatal clinic (missing = 2, 1.6%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003eMaternal-Fetal Medicine Service (GOLD)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e18.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003ePerinatal Loss Service (PLS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003ePregnancy Drugs and Alcohol Service (WANDAS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e8.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003ePreterm Birth Prevention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003eChildbirth and Mental Illness Service (CAMI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003eAdolescent Pregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e10.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003eRed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e20.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003eBlue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e8.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003eGreen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e8.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003eOrange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003eCommunity Midwifery Program (CMP)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003eFamily Birthing Centre (FBC)/Midwifery Group Practice (MGP)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e12.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003e\u003cem\u003eNumber of antenatal medical admissions (missing=10, 7.9%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003e0 admissions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003e1 admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e70.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003e2 admissions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e16.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003e3 admissions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e5.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003e4 admissions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003e5 admissions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003e6 admissions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003e8 admissions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003e\u003cem\u003eLength of postnatal admission following birth (missing=3, 2.4%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003e\u0026lt; 24 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e10.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003e1-5 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e81.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003e6-10 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003e\u0026gt; 10 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 151px;\"\u003e\n \u003cp\u003eMdn (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003eMin-Max\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003eNumber of Mental Health Service Appointments Booked (missing=1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e10 (5 - 16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1-45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003eNumber of Mental Health Service Appointments Attended (missing=1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e9 (4 - 14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1-43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003ePercentage of Mental Health Service Appointments relative to Booked (missing=1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e100.0 (88.2 - 100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e40 - 100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 616px;\"\u003e\n \u003cp\u003e^Valid percent adjusted for missing in the denominator.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"605\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"bottom\" style=\"width: 605px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 5.\u0026nbsp;\u003c/strong\u003eDelivery and neonatal outcomes for\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003epatients utilising Sensitive Care Birth Plans at KEMH (service)and all KEMH (service) pregnancies.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 73px;\"\u003e\n \u003cp\u003eSCBP Baseline Cohort (\u003cem\u003eN\u003c/em\u003e =126)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 93px;\"\u003e\n \u003cp\u003eAll KEMH (service) (\u003cem\u003eN\u003c/em\u003e =5,401)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"bottom\" style=\"width: 146px;\"\u003e\n \u003cp\u003eRisk Ratio\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(95% \u003cem\u003eCI\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003e%^\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 42px;\"\u003e\n \u003cp\u003e%^\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eSpontaneous labour (missing = 1, 0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e33.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e2,196\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e40.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e0.83 (.64, 1.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eInduction of labour (missing = 1, 0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e37.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e1,955\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e36.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e1.04 (.83, 1.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eAugmentation of labour (missing=2, 1.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e12.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e555\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e10.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e1.26 (.79, 2.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cem\u003eMode of birth (missing = 4, 3.2%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eStandard vaginal delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e46.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e2,715\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e50.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e.93 (.77, 1.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eAssisted delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e9.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e648\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e12.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e.75 (.43, 1.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eAssisted - forceps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eAssisted - vacuum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eCaesarean section\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e44.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e2038\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e37.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e1.17 (.96, 1.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eUnscheduled\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e22.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e1147\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e21.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e1.04 (.74, 1.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eCategory 1: Urgent threat, delivery within 30 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eCategory 2: Maternal or fetal compromise, delivery within 60 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e10.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eCategory 3: Earlier than planned by no compromise\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e8.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eCategory 4: Elective time that works for woman and service\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e22.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e891\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e16.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e1.34 (.96, 1.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003ePreterm labour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e19.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e1,003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e18.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e1.03 (.71, 1.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eSCN/NICU admission (missing = 3, 2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e46\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e37.7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1,128\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e20.9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.79*** (1.42, 2.26)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 605px;\"\u003e\n \u003cp\u003e^Valid percent adjusted for missing in the denominator.\u003cbr\u003e\u0026nbsp;***p\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":true,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"childbirth trauma, antenatal intervention, posttraumatic stress disorder post-childbirth, trauma informed care","lastPublishedDoi":"10.21203/rs.3.rs-6644068/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6644068/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground.\u003c/h2\u003e \u003cp\u003eDespite global recognition of childbirth trauma, as well as identifiable factors in pregnancy that may increase its occurrence, there is an absence of accessible and cost-effective primary (i.e., before childbirth) antenatal intervention. This study introduces an antenatal intervention, Sensitive Care Birth Plans (SCBP), currently implemented at the (blinded for peer review) Women and Newborn Health Service (WNHS) (service) in Western Australia (service location) and provides the maternal and infant characteristics of women accessing it for childbirth trauma.\u003c/p\u003e\u003ch2\u003eMethods.\u003c/h2\u003e \u003cp\u003eData was drawn from 126 patient files (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;30.34 years, 14.1\u0026ndash;44.4 years) identified with SCBPs from January to December 2022 at WNHS (service) in a retrospective file review.\u003c/p\u003e\u003ch2\u003eResults.\u003c/h2\u003e \u003cp\u003eMost women were diagnosed with a neurotic, stress-related and somatoform disorder (85.3%). There were high prevalences of childhood and adulthood trauma (63.5% and 63.2%, respectively), childbirth trauma (64.3%) and perinatal loss (54.1%). High rates of service use for the sample, with a 79% (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) increased likelihood of infant admission to the Special Care Nursery, and elevated antenatal admission days (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.72, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5.27), and caesarean section delivery recorded for 44.3% of women.\u003c/p\u003e\u003ch2\u003eConclusions.\u003c/h2\u003e \u003cp\u003eBy understanding the profile of women receiving SCBPs, this study may inform a future pilot study to explore the experience of this intervention. SCBPs have the potential to provide a model for perinatal services of equitable and effective antenatal psychological intervention to enhance maternal and infant outcomes and facilitate maternity care in the context of an increasing emphasis on positive childbirth experience.\u003c/p\u003e","manuscriptTitle":"Application of trauma informed care for childbirth trauma: The clinical profile of Australian patients accessing a tertiary antenatal intervention","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-24 06:06:38","doi":"10.21203/rs.3.rs-6644068/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-07T14:07:04+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-30T05:53:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-26T01:04:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"73338212192016077687291359262310191121","date":"2026-03-23T01:18:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"66225192521536617959207169778015377094","date":"2026-03-19T22:22:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"118288450353978296641358673791026002582","date":"2026-03-19T21:52:33+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-21T09:59:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-16T13:12:27+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-23T10:59:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-21T11:48:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-05-21T11:47:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7f444872-83dc-4aeb-965c-5aa1330724b1","owner":[],"postedDate":"July 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-18T13:53:57+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-24 06:06:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6644068","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6644068","identity":"rs-6644068","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}