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MAMA Factsheets

What do I need for a Homebirth?

Items for a homebirth

For the birth

  • At least 8 old towels
  • 4 face washers
  • hot water bottle/ oil heater to warm baby rugs
  • 2 buckets
  • garbage bags
  • heater/cooler for house temperature
  • plastic sheets/ curtain fabric to protect furniture
  • massage oil
  • ice
  • straws
  • juice/gastrolyte
  • icy poles
  • rescue remedy
  • blueys (supplied by midwife)
  • camera/video camera
  • sieve (for water births)
  • box of disposable gloves
  • mirror

For the baby

  • ‘fish and chip parcel’ – two baby wraps wrapped around a hat, singlet and hot water bottle
  • paw paw ointment
  • nappies

After the birth

  • 2 x packs, maternity pads
  • digital thermometer
  • arnica
  • manuka honey
  • calendula

Important notes

  • Pack a hospital bag in case of an emergency
  • Put all items for a homebirth in one spot (eg in a tub) for the midwives to find easily
  • Put a plastic sheet on the bed to protect the mattress
  • keep a full tank of petrol in the car and have a baby seat fitted
  • have plenty of pre-prepared meals for the postnatal period

Morning Sickness

Although Morning sickness is a common pregnancy ‘side effect’, it does not make it any easier for the two thirds of pregnant women who will experience morning sickness to some extent. It most commonly occurs in the first trimester (usually between weeks four and twelve), however some women may have it for the entire duration of their pregnancy. It usually occurs in the morning, hence its name, however it can happen at any time of the day (Fraser & Copper, 2003). The symptoms of morning sickness include nausea and vomiting, decreased appetite and in some cases may lead to anxiety and depression. In most cases, morning sickness does not have any long term health effects for the mother or unborn child. However, for some women, morning sickness can make them extremely ill, requiring hospitalisation for weight loss and dehydration. This severe form of morning sickness is known as hyperemesis gravidarum (Fraser & Cooper, 2003). In this case, if left untreated, the baby can also suffer from lack of nutrients.

Tips on how to cope with morning sickness:

  • eat small meals regularly
  • sip plenty of fluids regularly
  • add ginger to your food, drink ginger tea or take ginger tablets
  • limit spicy and fatty foods, or anything that makes you feel nauseated
  • avoid cooking and preparing foods; this can make you feel sick
  • for those who regularly exercised pre-pregnancy, exercise can help
  • try acupuncture or acupressure to relieve the nausea

MAMA Says: Acupuncture is the most effective non-medication therapy we recommend. Book in with our acupuncturist and try it for yourself!

For more information, visit


  • Fraser & Cooper (2003). Myles Textbook for Midwives, Ed.13.

Maintaining and improving Iron levels

What is Iron?

Iron is an essential element that your body uses to produce red blood cells. One of the primary functions of red blood cells is to carry oxygen around your body. Haemoglobin is the protein in the red blood cells that carries oxygen. When health professionals test your haemoglobin level, it gives them ‘a gauge of the oxygen carrying capacity of the Red Blood Cells’ (Frye, 2006, p.580). When you iron level is low, it in turn affects your oxygen carrying capacity, which can make you feel lethargic.

What are ‘normal’ levels of iron in pregnancy?

The mother’s blood volume expands by 50%-60% in pregnancy (with peak volume at around 30 weeks) (Frye, 2006). This is to ensure a good blood supply to the most important organ of pregnancy; the placenta. It also allows for a significant amount of blood loss after birth.  However, it is the blood volume (also called plasma) not the red blood cells that increase, meaning that the red blood cells actually become diluted. Just like cordial. This means that in the first trimester of pregnancy, your haemoglobin level will drop, and will increase again (after the volume expansion plateaus around the 30th week) towards the end of pregnancy. In other words, it is normal for haemaglobin to drop in the first trimester of pregnancy due to the dilution of the blood (hence why most women are tired in this period), and it should be back up to the pre-pregnancy level at around 30 weeks. The World Health Organization defines anaemia (another word for iron deficiency) in pregnancy as a haemaglobin below 110g/L. Bryant & Larsen (2009) state that women with a ferritin of less than 10-15ng/ml are iron deficient.

Why is it important in pregnancy?

During pregnancy, your iron demands increase to account for the increased volume of blood circulating around your body, which is to ensure your baby gets enough nutrition through the placenta.

Iron demands in pregnancy and the puerperium

  • Increase in the red blood cell mass 400-500mg
  • Demands of the fetus and placenta 300mg
  • Blood loss at delivery and placental loss 200mg
  • Lactation 1mg/day

(Bryant & Larsen, 2009, p.17).

How do I know if my iron level is low?

You may be:

  • feeling fatigued
  • pale
  • short of breathe
  • less hungry

Blood tests are definitive; your health care provider may decide to do a Full Blood Examination (FBE) to test your Haemoglobin (Hb), and Iron stores (ferritin).

How do I Increase my iron in pregnancy?

An ‘acidic’ environment in the gut improves iron absorption. For this reason, antacid medications should be avoided taken at the same time as iron rich foods or supplements. Tannin also decreases the absorption of iron; tannin is in tea so avoid a cuppa with your iron intake. On the other hand, vitamin C may increase acidity and in turn absorption, so have vitamin C rich foods (such as red capsicum) with your iron intake. The best way to increase your iron in pregnancy is through your diet. If this is not sufficient, you may be advised to take an iron supplement. Most iron supplements cause constipation, so if this is something you are prone to, ask your health professional for a brand that minimises this.

Foods rich in Iron:

Nettle Leaf (comes in tea form), dark green vegetables such as spinach, prunes, grape juice, kidney, oysters and scallops (Frye, 2006). Please note: whilst seafood is a great source of iron, seafood should be cooked before eating in pregnancy due to the risk of listeriosis.

Through tablets:

There are many different tablets and liquids available to increase your iron. Only take supplementary iron if this is recommended by a health care professional.

Bryant & Larsen state that ‘only approximately ten per cent of oral iron is absorbed’ (2009, p.18). This means that from a tablet containing 100mg of elemental iron, 10mg will be absorbed.

Floradix liquid iron supplement

Iron Supplement Brands and what they contain:

  • Floradix; Iron (from ferrous gluconate) 7.50mcg (available to purchase on our online shop)
  • Fefol: Ferrous Sulphate 270mg (equivalent to 87.4mg of elemental iron) & Folic Acid 300mcg
  • Ferro-F-Tab: Ferrous fumarate 310 mg Folic acid 0.35 mg
  • Dartnell’s pregnancy tonic: 36mg of ferrous phosphate per dose. *States it does not cause constipation or stomach upsets.
  • Spatone: (per sachet) 5mg Free Ferrous Ionic state (Fe ²+ clinically proven 26 to 40% bioavailability compared to an average 5 - 20% from food and 3 -10% from iron pills)

MAMA says: if you are suffering from nausea and vomiting in the first trimester eat whatever you can; this is not the time to try to increase your iron! Hopefully you can concentrate on this in the second trimester.


  • Bryant, C., & Larsen, S. (2009). Anaemia in pregnancy. Blood. 11(3), 17-18
  • Frye, A. (2006). Holistic Midwifery: A comprehensive textbook for midwives in homebirth practice. Oregon: Labrys Press.

Tests & Investigations explained; Toxoplasmosis

Toxoplasmosis is caused by a parasite, Toxoplasma gondii. This infection is not serious for you but can be for your developing baby. Although mostly exposure carries no symptoms, the most common sign in symptomatic patients is enlarged lymph nodes, especially around the neck or muscular pain and fever. Should exposure to this parasite occur to a woman during pregnancy, it can affect the unborn baby with varying degrees of severity. Depending on the time of exposure during pregnancy and fetal development, symptoms can vary from mild to eye disorders, liver or brain damage.

A women can acquire Toxoplasmosis from contact with infected cat faeces (directly or indirectly through soil), eating raw or uncooked food that is contaminated, not washing hands thoroughly after handling raw meat, gardening with direct contact in soil, from contaminated raw vegetables or fruits or drinking unpasteurised milk.

Women are not routinely screened for this antenatally, but you can have a blood test to check your immunity. If there is concern of exposure during pregnancy, Amniocentesis can be performed to detect infection, but this cannot reveal the severity of exposure. Babies can also be tested after birth.

There are several steps you can take to avoid infection: 

• Always wash your hands before preparing or handling food. 
• Make sure that all meat and chilled ready-meals are thoroughly cooked before you eat them. 
• When you have handled raw meat, remember to wash your hands, cooking utensils and surfaces thoroughly afterwards. 
• Don't eat cold processed meats, such as ham or salami. 
• Avoid unpasteurised milk and products made from it. 
• Always wash fruit and vegetables thoroughly.
• If you're gardening or handling soil or sand, wear gloves and wash your hands afterwards in case you have come into contact with cat faeces in the soil.
• Wash your hands thoroughly after contact with sheep at farms and outdoor play centres with animals, and avoid handling newborn lambs. 
• If you have a cat, use gloves when emptying the litter tray and wash your hands afterwards. Empty the litter tray daily.

MAMA Says: If you have a cat, maybe ask someone else to deal with the litter tray while you’re pregnant.

For more information, visit

Tests & Investigations explained; Listeriosis

Listeria is an illness usually caused by eating foods contaminated with the bacteria known as Listeria monocytogenes. Other less common forms of transmission are indirect contact with contaminated soil, water or sewage. Listeriosis is a serious disease in pregnant women and their babies, newborns, the elderly and people with weakened immune systems.

The incubation period (between infection and symptoms) can vary but on average is about three weeks. Symptoms include: fever, muscle aches, and sometimes gastrointestinal symptoms such as nausea and diarrhoea. In the more severe form, symptoms also include collapse and shock. Infection during pregnancy can lead to miscarriage, stillbirth and infection of the newborn.

Listeria is widespread throughout nature, being commonly carried by many species of both domestic and wild animals. Outbreaks of illness have been associated with raw or contaminated milk, soft cheeses, prepared salads (for example, from salad bars), unwashed raw vegetables and ready to eat meat such as paté. People who are at risk can contract listeriosis through eating food contaminated with the Listeria bacteria. Babies can be born with listeriosis if their mothers eat contaminated food during the pregnancy.

To prevent listeriosis:

  • Thoroughly cook raw food from animal sources, such as beef, lamb, pork, or poultry
  • Wash raw vegetables and fruit thoroughly before eating
  • Keep raw meat separate from vegetables, cooked foods, and ready- to-eat foods (that is, do not allow the blood from raw meat to come into contact with other food)
  • Use separate cutting boards for raw meat and foods that are ready to eat (for example, cooked foods and salads)
  • Avoid unpasteurised milk or foods made from unpasteurised milk (for example, soft cheeses)
  • Wash your hands before and after preparing food
  • Wash knives and cutting boards after handling uncooked foods
  • Wash your hands after handling animals
  • Perishable foods should be stored in a cold (less than 5 degrees Celsius) refrigerator and be washed and eaten as soon as possible.

People at increased risk of listeriosis should not eat:

  • Pre-packed salads
  • Pre-cut fruit
  • Pre-cooked chicken
  • Raw meats
  • Cold delicatessen meats
  • Paté
  • Raw seafood
  • Smoked fish
  • Unpasteurised milk or milk products
  • Soft serve ice cream
  • Soft cheeses such as brie, camembert, ricotta, or blue-vein
  • Sprouted seeds and raw mushrooms

The diagnosis of listeriosis can be confirmed by a blood or other tests. Treatment involves antibiotics and supportive therapy. When infection occurs during pregnancy, antibiotics can often prevent infection of the foetus or newborn.

MAMA Says: Unlike most other food-contaminating bacteria, Listeria can grow in the refrigerator. However, Listeria bacteria are readily killed during cooking. So, think freshly prepared foods, served hot and if re-heating left-over foods the next day heat until piping hot.

For more information, visit

Tests & Investigations explained; Cytomegalovirus (CMV)

Cytomegalovirus (CMV) is a common viral infection and a member of the herpes family. Related viruses include Epstein-Barr (causes glandular fever), varicella-zoster (causes chicken pox) and herpes simplex (causes cold sores). This viral infection can be spread through coughing, contact with blood, urine or faeces, or via the mucous membranes such as the mouth and genitals.

In healthy people, CMV infection causes nothing more than a flu-like illness that lasts a few days. In certain people, however, including transplant patients and pregnant women, the effects can be much more serious. Once a person has contracted CMV, they will carry it for life. This is because the virus lies dormant inside the body and may or may not reactivate itself at any time.

Women can catch CMV during pregnancy and pass it on to the baby – this is called congenital CMV. Around one in ten infected babies will have lasting problems. These can include deafness, poor eyesight, intellectual disability and an enlarged liver or spleen.

Pregnant women should wash their hands after handling bodily secretions from babies or children, for example after changing nappies or wiping noses.

Treatment depends on the severity of the condition. In a healthy person, bed rest, drinking plenty of fluids and medical supervision are all that is generally required. Pregnant women and patients with suppressed immunity need careful medical monitoring and frequent testing, including blood, sputum and urine tests. Antiviral medication may be prescribed.

MAMA Says: Remember good hand hygiene and consult medical advice if you are concerned regarding exposure.

For more information, visit

Looking after your perineum & care for stitches after birth

The Perineum is the area located between the vagina and back passage (anus) and has an amazing ability to gently stretch and give to allow the birth of our babies. Below are some methods of prevention for perineal trauma. Some points are evidence base, some are common sense, some are just comforting for the woman at the time and some just work!

Good nutrition and health equals strong elastic tissue and rapid healing after the baby is born. Focus on a well balance diet throughout your pregnancy. Eat a large variety and lots of fresh seasonal foods.

Sore, irritated, swollen perineal tissue is not likely to be as pliable, can tear easily and heals poorly. We advise to avoid perfumed soaps and sprays and sometimes panty liners can cause irritation. Comfortable cotton underwear is encouraged and prompt follow-up on yeast or other infections.

Perineal massage; anecdotally, midwives and women all over the world believe that perineal massage has helped avoid tearing and episiotomy during childbirth. The concept of stretching of the perineum by placing two thumbs into the vagina and gradually stretching the perineum open and out is thought to be beneficial. Some midwives recommend evening primrose, olive oil or unscented almond oil for this. Unfortunately, it is physically challenging in later stages of pregnancy and is generally taught as a couple’s activity. Evidence on perineal massage is shown to be effective for women having their first baby and if commenced after 34 weeks gestation (Yates, 2010).

A dilating balloon device is currently being promoted to increase vaginal elasticity antenatally. Experts are challenged to see the benefits of dilating a woman’s vagina to 10cm without actually being in labour and giving birth. The vaginal/perineal tissue does this particularly well when there is gradual dilation in labour, with sufficient expulsive urge, support and encouragement.

Management from your care provider of the second stage (the pushing part) of labour is critical to preserving the integrity of the perineum. We should observe the rest time between contractions and wait for the physiological urge to push occur. There is a significant trend towards poorer perineal outcomes when directed forceful pushing is used, with evidence that pushing on command and expulsive pushing (holding your breath, chin down on chest etc) contributes to pelvic floor damage, fetal distress, exhaustion and perineal tears.

A meta-analysis of randomised controlled trials showed that spontaneous vaginal birth reduced the incidence of perineal trauma (Yates, 2010). The absence of fear and embracing of trust of your body and the birthing process can help reduce the likelihood of tears.

Choosing a care giver who allows you to adopt your birth position instinctively is important with the avoidance of Lithotomy (legs up in stirrups) which is the worst position for pain and tearing. The avoidance of forceps or vaccum deliveries and epidural or local anaesthesia that will numb the area all play a part in preventing trauma.

Placing warm packs over the perineum to help relieve the burning sensation during crowning can be most comforting.

A trusting relationship with your birthing carer will allow you to work with your body and your baby during the process. Humour can help women to relax and a close interaction between midwife and the woman throughout with gentle coaxing and quiet, peaceful talking to encourage slow birth of the head after crowning. The most effective preventative for perineal trauma in our experience is the trusting relationship between mother and midwife developed through pregnancy. Discussion occurs about what happens in the second stage and how the midwife will provide encouragement and support to get through this overwhelming experience.

Below are our recommendations in dealing with perineal soreness, care after birth and how to care for stiches.

  • With all normal births try to minimize movement for the first week to aid healing
  • Apply ice to your perineum if there is swelling for the first 24 hours
  • If you had stitches or an episiotomy focus on a well-balanced diet of fresh seasonal foods
  • Avoid constipation by increasing your fruit, fluids and fibre after birth
  • Have salt baths for the first few days after birth in a very clean bath (½ fill the bath, ½ cup salt, sit for ½ an hour), but do not submerge your breasts or baby in the salt water.
  • use salt washes after using the toilet to keep the area clean and minimise the chance of infection
  • Take arnica tablets or pillules regularly (follow instructions on the packet)
  • Allow 4-6 weeks for the area to heal completely and consider use of a lubricant when you are ready to resume sexual activity

MAMA Says: MAMA believes a loose open jaw may help to have a loose open vagina. The space held for the woman in the birth room may also greatly help reduce the chance of perineal tears.

For more information, visit

Exercise in the antenatal and postnatal period

Exercise in pregnancy is essential. Exercise will help you remain active, mobile and prevent you gaining excessive weight in your pregnancy. Unless you have complications, it should be possible to enjoy some level of physical activity throughout most of your pregnancy. You may need to modify your existing exercise program or choose a suitable new one if you were not a regular exerciser pre pregnancy.

Some of the benefits of exercising regularly throughout your pregnancy include:

  • Optimises your chances of a quick, easy birth
  • Increases your energy
  • Improves the strength of your back muscles which can help manage back pain and strain as your belly grows
  • Improves posture
  • Releases endorphins helping you feel good during your pregnancy
  • Stress relief
  • Improved sleep and management of insomnia
  • Preparation for the physical demands of labour
  • Can help you get your baby into the right position for birth
  • Faster recovery after labour
  • Faster return to pre-pregnancy fitness and healthy weight
  • Increased ability to cope with the physical demands of motherhood

Women should discuss their exercise plans with their midwife or doctor. Depending on your previous exercise program, you may be able to continue this during pregnancy; however you should check this first to receive clearance.

If you have been cleared to exercise, it is recommended that you:

  • Engage in at least 30 minutes of moderate-intensity physical activity on most days of the week
  • Combine Strength and Aerobic exercise
  • Let your body be your guide and back off if you feel faint, weak, or unwell
  • Increase your water consumption on your exercise days
  • Avoid over heating during exercise and back the intensity off if you feel this coming on
  • Don’t forget the pelvic floor

Suggested exercise activities during pregnancy

Activities that are generally safe during pregnancy, even for beginners, include:

  • Walking
  • Swimming
  • Yoga
  • Cycling – outdoors or on a stationary bicycle
  • Exercise in water (aquaerobics)
  • Stretching
  • Dancing (especially Belly Dancing)
  • Pilates
  • Pregnancy exercise classes


There are some exercises that involve positions and movements that may be uncomfortable or harmful for pregnant women. General cautions include:

  • Contact sports or activities that carry a risk of falling (such as trampolining, rollerblading, downhill snow skiing, horse riding and basketball)
  • Competition sports – depending on the stage of pregnancy, the level of competition and your level of fitness
  • After about the fourth month of pregnancy, exercises that involve lying on your back – the weight of the baby can slow the return of blood to the heart. Try to modify these exercises by lying on the side.
  • In the later stages of pregnancy, activities that involve jumping, frequent changes of direction and excessive stretching.

Postnatal recovery

Resuming gentle exercise can be started within the first few weeks after birth, if you feel up to it. As a rule, your post birth recovery takes 4-6 weeks so after this timeframe you should be ready to resume your regular exercise routine. Remember the Relaxin hormone remains in your system for some months after birth so take care with vigorous exercise and stretching. Like in pregnancy, stay well hydrated, particularly if you are breastfeeding and gently increase your duration slowly as your fitness levels improve.

MAMA Says: Many women find themselves feeling heavy and extremely uncomfortable in late pregnancy. You don’t have to feel this way and the key is regular exercise.

For more information, visit

Diastasis of the Rectus Abdominus Muscle (DRAM)

This is the separation of the connective tissue in between the two strap like muscles that run down your abdomen (Gilleard & Brown, 1996). This often occurs during pregnancy as a result of the baby growing. The separation of this muscle usually happens to some degree in the pregnancy but for some women it may be quite severe. Left untreated post birth this can lead to posture problems, back pain or pelvic floor dysfunction.

A DRAM is measured by health professionals in finger widths after birth. Usually it self resolves at around four weeks after the baby’s birth. If it does not, you may need to do some exercises to strengthen your abdominal muscles. It is best to see a Physiotherapist or healthcare practitioner who specialises in DRAM to receive appropriate treatment and follow up. Exercising too hard or with the wrong type of exercises (such as sit ups) can further extend the DRAM therefore appropriate follow up is essential.

MAMA Says: After you have had your baby ask your midwife how many finger widths your DRAM is. See our specialised Women's Health Physiotherapist for exercises to help your DRAM come back together!

For more information, visit

Pelvic Floor Exercises

The pelvic floor is a hammock of muscles which run from the pubic bone all the way back to the tailbone (coccyx) and support the uterus, bladder, vagina and bowel. The urethra, vagina and anus all have sphincters which pass through the pelvic floor. Pelvic floor exercises are most important for all women and these are also known as keigel’s exercises. Under the influence of relaxin, all of the tissues in the body relax. The exercising of the pelvic floor muscles during pregnancy and after the birth prevents things like vaginal prolapse and incontinence. Pelvic floor exercises are designed to improve muscle tone and integrity and can prevent the need for corrective surgery after birth or later in life.

If the muscles are weakened, the internal organs are no longer fully supported and you may not be able to control your urine, wind or bowels. If you have symptoms including difficulty holding onto urine, wind or bowels this can be a sign that your pelvic floor muscles are weak.

The pelvic floor can be weakened in many ways, including:

  • Pregnancy  - the weight of the uterus
  • Vaginal childbirth, which overstretches the muscles
  • Obesity
  • Chronic constipation and associated straining to pass motions
  • Chronic cough
  • Some forms of surgery that require cutting the muscles
  • Lower levels of oestrogen after menopause

In order to strengthen your pelvic floor you must know how to correctly perform the exercises. Squeeze the sphincters from the vagina, urethra, and back passage as if you were tightening the vagina, stopping the flow of urine and holding back wind.

The exercises

You can perform these exercises lying down, sitting or standing. Ideally, women should perform these daily but even up to three times a day is preferable.  Before you start, focus your attention to your pelvic floor muscles. Avoid contracting your abdominal muscles and try not to bear down or hold your breath. Gradually squeeze all three sphincters and increase the tension until you have contracted the muscles as hard as you can. Release gently and slowly. Then perform the exercises, which include:

  • Squeeze slowly and hold as strongly as you can for 10 seconds while breathing normally. Release slowly. Repeat 10 times.
  • Perform quick, short, strong squeezes. Repeat 10 times.

MAMA Says: See our specialist Women's Health Physiotherapist for an individualised examination of your pelvic floor, and plan to suit you!

For more information, visit

Vaginal Bleeding after birth

Are you in Melbourne and would like to see or speak to a midwife about bleeding in pregnancy or the postnatal period? Call us now on 9376 7474; a Midwife is available any time!

It is normal to have bleeding after your baby’s birth, whether your baby was born vaginally or by caesarean. More often the blood loss is heavier after a vaginal birth. An average amount of blood when a women gives birth is between 200-300ml. Your body prepares in pregnancy to lose a significant amount of blood immediately after the birth, with a large increase in the blood volume. Lochia is the name given to postnatal bleeding.

Lochia is very similar to the bleeding you experience during your menstrual period; however, it is much heavier. It typically begins in the hours immediately following birth and usually continues for two or three weeks. However, in some women lochia can last for up to six weeks. In the first day or two it will be like a heavy period and it will get progressively lighter.

Symptoms of Lochia

Lochia usually begins as a bright red discharge from the vagina. This blood typically continues to be bright red in colour for between four and ten days. After ten days, your lochia will become a pink colour, eventually changing to a clear-yellowish-white colour. This blood flow may be constant and even, or it may be expelled in intermittent gushes. Lochia may also be accompanied by numerous small blood clots, about the size of a grape (Myles, 1999).

Dealing with Lochia

  • Rest as much as you can and avoid excess standing and walking (this will exacerbate the blood flow)
  • Use heavy duty super pads to soak up the blood
  • Do not use tampons for at least six weeks after pregnancy. Tampons can introduce bacteria in to the vagina and uterus, causing infection

Warning Signs

Typically, lochia is not the result of any health complication and will end on its own when your body is ready. However, some women do experience problems with their postnatal bleeding. If you experience any of the following signs, call your health care provider or visit your nearest hospital emergency department -

  • Bright red discharge for more than seven days after birth
  • Discharge that smells bad
  • Fever and chills
  • Abnormally heavy bleeding
  • Large clots continuing more than seven days after birth

Postnatal Haemorrhage

Postnatal haemorrhaging is a more severe type of post-pregnancy bleeding. If you lose more than 500 ml, you are classified to have had a postnatal haemorrhage. Postnatal haemorrhaging can be a very dangerous condition and is associated with various complications including heavy blood loss and even maternal death (Myles, 1999). It usually begins in the 24 hours immediately following childbirth (primary postnatal haemorrhage); however, it can occur anytime during the six weeks following delivery (secondary postnatal haemorrhage).

What causes Postnatal Haemorrhage
The most common cause of postnatal haemorrhage occurs when the uterus does not contract after birth. This allows the uterus to continue bleeding and can result in massive blood loss. Other causes include:

  • Failure to deliver all of your placenta and membranes
  • Forced removal of the placenta
  • Trauma to the uterus, cervix or vagina during delivery

Symptoms of Postnatal Haemorrhage

Every woman is at risk for developing postpartum haemorrhage. However, there are certain factors that will increase your risk although some may have a heightened risk. It is extremely important that every new mother knows how to recognize the symptoms of postnatal haemorrhage. Quick treatment is essential in order to prevent excessive blood loss. Symptoms include:

  • Massive blood loss
  • Passing large clots
  • Dizziness, light-headedness, or fatigue

Treating Postnatal Haemorrhage

Postnatal haemorrhage is usually taken very seriously. If you are suffering from this type of bleeding, you will likely be treated in hospital with uterine massage, anti-bleeding drugs, surgery if needed, blood transfusion if needed and in some rare cases hysterectomy if they bleeding cannot be stopped.

MAMA says: Continue an iron rich diet after the baby is born! Consider an iron supplement if your iron levels are low post delivery.

For more information, call our MAMA centre and speak to a midwife.

Postnatal Depression

Are you based in Melbourne and would like to see someone for postnatal depression? You can see one of our Midwives*, Psychologists* or Counsellors who can help you through this difficult time. Phone 9376 7474 to book, or send an appointment enquiry at the top of this page. *Medicare rebates are available.

Postnatal depression (PND) can be a devastating and debilitating illness that can persist and affect not just a new mother but everyone around her (PANDA, 2011). PND can be mild, moderate or severe and symptoms can begin suddenly after birth or appear gradually in the weeks or months during the first year after birth. PND can occur after miscarriage or stillbirth, normal or traumatic delivery, or caesarean delivery. PND happens not only after a first baby. It can occur after a third or fifth baby. Sometimes it happens after a first baby only. Sometimes it happens with a third baby, but not with the first two. Sometimes it happens after each pregnancy. A woman who has had PND has an increased chance of recurrence with a subsequent pregnancy (PANDA, 2011).

Symptoms of Postnatal Depression

Like with other forms of depression, the severity of PND depends on the number of symptoms, their intensity and the extent to which they interfere with activities of daily living. The combination and severity of symptoms will be different for every woman, resulting in many different appearances of PND.

  • Sleep disturbance unrelated to baby's sleep needs
  • Appetite disturbance
  • Crying or not being able to cry
  • Inability to cope
  • Irritability
  • Anxiety
  • Negative, morbid or obsessive thoughts
  • Fear of being alone or fear of being with others
  • Memory difficulties and loss of concentration
  • Feeling guilty and inadequate
  • Loss of confidence and self-esteem
  • Thoughts of harm to self, baby or suicide (PANDA, 2011).

Contributing Factors

PND is a multi-factorial condition with biological, psychological and social factors all playing varying levels of involvement. This is why all women who suffer from PND will have their own unique symptoms and experience.

It is essential to seek professional advice should any of the above symptoms exist in your life after you baby is born. Seeking professional help as early as possible will allow a prompt treatment plan to be developed.

MAMA says: The best person to detect any form of PND is your partner. Keep communication channels open after delivery and talk through your feelings and any worries you may have.

Partners suffer from PND too; be aware of each other’s mood around this time and seek help if you need to!

For more information, visit, or for help call PANDA on 1300726306 or your MAMA midwife.

Physical care after a Caesarean section

You will be encouraged to get out of bed and mobilise within the first 24 hours after surgery. This will help start the healing process and get you used to moving around with your incision.

  • If staples were used for your incision they will most likely be removed around day 5-7 after birth
  • If stitches were used, they will be dissolvable ones
  • After your dressing has been taken down there may be steri strips left on the wound. These will start to peel off over the next few days and this is when it is time to remove them completely
  • You can shower normally and wash your body with soap. That soap will run over the wound; that is ok. Just avoid rubbing soap into your wound over the first week or so
  • You should look at your wound every day over the first few weeks. The wound edges should be together and there should be no gapping of the incision. There should not be redness, ooze or heat coming from the wound and surrounding skin
  • Make sure you watch for fever or pain, which can be a sign of infection
  • Wear underpants in the first few days that are a big high cut style to come up and over your wound

Things to avoid

  • Avoid taking baths until your incision is healed and you are no longer bleeding (up to 6 weeks)
  • Public pools and hot tubs
  • Lifting anything heavier than your baby
  • Repeatedly using stairs
  • Exercise until your health care provider says it’s safe
  • Driving within the first 4-6 weeks

Reasons to seek medical advice

  • Fever
  • Severe headache that begins right after birth and does not let up in intensity
  • Sudden onset of pain in the abdominal area, such as tenderness or burning
  • Foul smell from vaginal discharge
  • Sudden onset of pain in the incision area that can include a pus discharge
  • Swollen, red, painful area in the leg
  • Burning urination or blood in the urine
  • Appearance of rash or hives

Wound care after Caesarean birth

The days following the birth of your baby, can be challenging in many ways. This time can be even more challenging for a mum who has undergone a caesarean delivery. After all births, women must take time to allow their body to rest and heal.

MAMA says: Focus on a well-balanced diet of fresh seasonal foods postnatally to aid in wound healing and avoid constipation.

Vitamin K injection for the Newborn

After birth, all hospitals in Victoria have a policy for babies to be offered vitamin K, either orally or by intramuscular injection. This has been an option in most areas for over thirty years and it is thought by the medical profession to be an important prophylactic measure in preventing newborn Vitamin K deficiency. The medical information regarding this is that it is perceived all babies are born with low levels of vitamin K. Babies need vitamin K to prevent haemorrhagic disease (HDN), which can cause serious complications.
Breast milk is known to carry ‘low’ levels of vitamin K, which are not high enough to prevent HDN.
The babies most at risk from HDN are those who have traumatic births (clinically, this might include babies who are delivered by forceps, ventouse or emergency caesarean section, or babies who show bruising). The risk of a baby who is not given vitamin K, and has low risk factors, developing HDN is between 1 in 10,000 and 1 in 25,000 (Wickham, 2001). Babies who are at high risk of HDN can have a chance as high of 1 in 120.

Babies, who are born vaginally without undue trauma, are at the very lowest risk of developing HDN.However, there is still a risk that a baby who is born vaginally will develop HDN.
Some studies have found a possible link between intramuscular vitamin K and childhood cancer. This is not conclusive evidence (Wickham, 2001), and The National Health and Medical Research Council has looked carefully at these studies and other evidence, and has concluded that vitamin K is not associated with childhood cancer, whether it is given by injection or by mouth.

MAMA Says: In general, babies are born with pretty much everything they need. However, as we are unsure as to why some babies born without ‘risk factors’ still develop HDN, giving vitamin K to your newborn baby is a simple way of preventing a very serious disease.

For more information:

  • Visit
  • Vitamin K – An Alternative Perspective, by Midwife Sara Wickham, AIMS Journal, Summer 2001, Vol 13 No 2
  • Visit

Hepatitis B Vaccine for the Newborn

Before or soon after you have your baby, your doctor or midwife will discuss Hepatitis B immunisation with you and will ask you to make a decision about whether you want your baby immunised. Hepatitis B is a serious disease that can be contracted throughout life. It is caused by a virus that affects the liver and can lead to liver cancer of liver failure later in life.

The Hepatitis B vaccine is an intramuscular injection given to babies after birth either within the first few hours or after a day or so. The baby will need three more doses of the hepatitis B vaccine to be fully immunised. These will be given at two, four and six months of age in combination with other routine childhood immunisations.

Common side effects of the Hepatitis B vaccine are

  • Mild fever
  • Joint pain
  • Irritability
  • Decreased interest in feeding in the first few days of life (

Whilst these common and perhaps transient side effects may be of little concern in an older child they are liable to be of much greater significance in a newborn baby who is already facing many challenges at this deeply important point in its life.

Challenges to the newborn include

  • Adaptation to extra uterine life – profound physical changes in all systems respiratory, circulatory, neurological, sensory, digestive/alimentary
  • Organisation of suck to enable feeding
  • Overcoming effects of pharmacological substances used in labour, birth and postnatally
  • Recovery from the traumatic effect of birth e.g. head moulding and other birth injury

All women are screened for Hepatitis B antenatally so that babes of positive mothers can receive both Immunoglobulin and vaccination at birth. This has been shown to be extremely effective in managing the risk of vertical (mother to baby) transmission.

The risk factors (for contracting the disease) are IV drug use, unsafe sexual practices and certain ethnic groups who have “high” endemnicity so may have a slightly elevated risk of transmission. These being Aboriginal, Torres Strait Islander and particular Asian groups (

The World Health Organisation (WHO) classifies Australia as a "low" risk for Hepatitis B with low endemnicity of <2%, transmission rates in infancy are "rare" and "infrequent" in childhood. The WHO recommendation is for universal Hepatitis B immunisation for “high” risk groups and the recommended program is for the full course of vaccination commencing after birth with the other three doses to follow.

If you are in the low risk group and would like to have your baby vaccinated against Hepatitis B consider delaying at a minimum of 24 hours post birth when your baby has stabilised or after a few days. Alternatively, if you have no risk factors and are not putting your baby into childcare within the first couple of months, consider delaying the first dose of the vaccine until your baby is two months old or later.

MAMA Says: A vaccination post birth is a big event for a newborn baby’s immune system. Research your risk factors and make an informed choice on if and when the best time for your baby to be vaccinated may be.

For more information, visit

Looking after yourself in the postnatal period

Your Perineum

If you have had a tear of any sort, we recommend applying manuka honey to the tear. Manuka honey comes in different grades and has antiseptic and healing properties.

We may recommend you to apply ice to your perineum if there is swelling.

  • Regularly use calendula or salt washes after using the toilet to keep the area clean and to aid healing
  • Take arnica tablets or pillules regularly (see packet for usage instructions).
  • If your perineum is causing a lot of discomfort, you can safely take paracetamol (panadol) and diclofenac (voltaren). Panadol and Voltaren work well in combination, and are both safe for breastfeeding.
  • If you did not have stitches, we will discuss trying to minimize movement for the first week to aid healing.
  • Sleep
  • Newborns are usually nocturnal, that is, that they are mostly awake during the night. This is because your hormones for breastmilk production peak at this time, and your baby can sense this.
  • Try to sleep during the day when your baby sleeps, knowing that it is normal for your baby to be awake at night time.

Food & Drink

  • Try to eat regular nutritious meals after the birth of you baby. Breastfeeding uses up a lot of energy and it is important to replace this with a balanced diet.
  • Your water requirements also increase when breastfeeding. The recommended intake is 3 Litres per day. Try to get in to the habit of having a glass or bottle of water next to you when you breastfeed your baby.

Pelvic Floor Exercises

Pelvic floor exercises are essential after pregnancy and birth, as there is always a degree of pelvic floor muscle weakness. One in four women who have had babies have problems with incontinence.

Only attempt to start these exercises when you feel up to it.


We believe that the use of water in labour has many advantages. According to a cochrane review in 2009, there is no evidence of increased adverse effects to the fetus/neonate or woman from labouring in water or waterbirth. We provide waterbirth as an option to our clients who wish to have a homebirth, and use of the pool at home in labour for women who wish to birth in hospital. Different hospitals have different views on waterbirth; if you wish to have a waterbirth in hospital it is useful to discuss it with the hospital staff during your pregnancy.

We hire pools and equipment for water birth if you have a MAMA midwife at your birth!


  • Evidence suggests that water immersion during the first stage of labour reduces the use of epidural/spinal analgesia as it minimises the pain effectively for most women
  • labouring in water and waterbirth increases maternal relaxation. Immersion helps relive anxiety and encourages women to let go and focus inward as labour progresses
  • Water relaxes the pelvic Floor muscles, as it softens the vagina, vulva and perineum and may lead to fewer injuries to these tissues.
  • Skin to skin time is facilitated.
  • Initial breast contact is easier to initiate as the mother is already naked.
  • The cord continues to pulse strongly for an extended period resulting in baby receiving his full blood volume.


  • You may not feel comfortable with wading in your own bodily fluids
  • If you are planning to birth in hospital, waterbirth may be against hospital policy, or there may be only one bath with limited availability



  • Balaskas, J. (2004). The waterbirth book. Thorsons: Harper Collins Publishers
  • Johnson, J., & Odent, M. (1995). We are all water babies. Berkeley: Celestial Arts
  •  Bertram, L., McLanahan, S., & Odent, M. (2000). Choosing waterbirth: reclaiming the sacred power of birth.


  • Burns, E (2006). Waterbirth: a natural intervention. British Journal of Midwifery. 14(9), 557.
  • Clift-Matthews, V. (2007). So much diversity in practice: caesarean or waterbirth? British Journal of Midwifery. 15(1), 4.
  • Cluett, E., & Burns, E. (2009).Immersion in water in labour and birth. Cochrane Database of Systematic Reviews.
Garland, D (2006). Waterbirth; an international overview. International Midwifery. 19(2), 24-25.

Garland, D (2006). Is waterbirth a ‘safe and realistic’ option for women following a previous caesarean section? completion of a three year data study. MIDIRS Midwifery Digest. 16(2), 217-220.
  • Gould, D. (2007). Waterbirth: from ordinary to extraordinary. British Journal of Midwifery.15(1), 24.
  • Miller, J., & Magill-Cuerden, J (2006). All women in labour should have the choice of waterbirth. British Journal of Midwifery.14(8), 484-485.

Birth Plan/Preferences

There are many formats of birth plans available on the internet.  Some hospitals, doctors and midwives have their own forms you can fill in. It will depend on your chosen caregiver as to how much attention they pay to your birth preferences.

Will it go in your file and never be looked at?

Will it get lost in the system?

Here are some handy tips to ensure your care providers pay attention to your written wishes.

  1. make it individualised!

Wether this is by writing a little blurb about you and your partner at the beginning, or providing a little photo or anecdote, having your birth preferences individualised in this way can remind your care provider that this is YOU writing the document, and these are YOUR wishes.

2.  have a Plan A, B, C...

By this we mean don't just put your 'ideal' (for example a natural birth), have preferences for in case of Caesarean section, as this will empower you in your decision making no matter what type of birth you have.

3. keep it simple

Even writing dot point. The simpler the birth document, the more likely busy staff are going to read it!

4. put it on coloured paper

Then it can't be missed in your file

5. keep a copy yourself

For your birth partner to refer to, and in case your care providers copy gets lost!



MAMA says: birth plans are a good tool for a couple to use for education, and to discuss between you and your support team what you want in certain labour and birth scenarios. 

TENS Machines

TENS is a very effective pain relief option during labour. Using electric pulse, it is a drug free pain management method which helps you to remain calm and manage contractions.

TENS machines are available for hire at MAMA, through TENS Australia. They cost $140 and  you will receive $40 deposit back upon return.

You can pick them up at our Kensington centre.

Please contact us should you wish to reserve a machine.

What are my pregnancy, birth and postnatal care options in Victoria?

I’m pregnant, what next?

You have just found out you are pregnant. Congratulations. You will probably have a mixture of feelings; fear, excitement, overwhelmed, or all of these! Many women who contact us feel daunted about what to do next, so we have put together some information to get you started.

Traditionally women will see their GP as the first point of contact, however MAMA midwives are also able to discuss your care options and order any tests or ultrasounds you may want or need throughout pregnancy. At this time we will be able to confirm you are pregnant, discuss your expected due date (based on a calculation using the first day of your last menstrual period, or the conception date, or from an early scan). We will also discuss your choices for pregnancy care including caregivers and hospitals and tests offered in pregnancy. We can also discuss how you are feeling at this time, and arrange any extra supports you may feel you need.

Who can provide care for me and my baby?

Your choices include a midwife, a general practitioner, an obstetrician, a paediatrician, a hospital team or a collaboration of any of the above.

Other people who can provide non-medical care for you include doulas, or other alternative health professionals that you usually use for your health care needs.

Which Health Professionals can provide care for me & my baby in Pregnancy, Birth and Postnatally?
A Paediatrician is a specialist in the care of a baby, a neaonatologist is a specialist in the care of a newborn (under six weeks). If you have chosen private maternity care with an obstetrician, your baby will most likely be seen by a paediatrician. If you have chosen public hospital care or care with the MAMA midwives, your baby will be seen by a paediatrician if necessary. It is best to choose WHO you would like to care for you throughout your pregnancy, as this might dictate where you can give birth.

Where can I choose to give birth?

Public hospital

In the public hospital system, pregnancy care usually takes place in the antenatal clinic with the hospital team. You are usually not guaranteed who you will see at each visit, unless you are in one of the small continuity of care models. Major public Hospitals are now ‘zoning’, which means you must attend your nearest public hospital as you will be in their ‘catchment area’. You can also choose shared care with a midwife or your GP, which means you see the midwife or GP for the majority of pregnancy appointments, and the hospital for a key 2-3 appointments.

Cost: hospital appointments are free in the public system, as well as any inpatient stays. Fees for appointments with the shared care provider are charged at the health professionals’ discretion. Ultrasounds are an out of pocket expense, unless there is seen to be a ‘medical need’, when you will have them done in the hospital.

MAMA Midwives are able to do shared care with most public hospitals, and provide labour & birth support at home and in hospital, no matter where you choose to birth! Book an appointment at the top of the screen to find out more!

Which public hospitals provide maternity services?

Angliss Hospital  
Albert St, Ferntree Gully, 3156 ph: 03 9764 6111

Box Hill Hospital 
Nelson Rd, Box Hill, 3128 ph: 03 9895 4640

Dandenong Hospital
 David St, Dandenong, 3175 ph: 03 9554 1000

Frankston Hospital 
Hastings Rd, Frankston, 3199 ph: 03 9784 7777

Healesville & District Hospital 
377 Maroondah Hwy, Healesville, 3777 ph: 03 5962 4300

Mercy Hospital for Women  
163 Studley Rd, Heidelberg, 3084 ph: 03 8458 4444

Monash Medical Centre Clayton 
246 Clayton Rd, Clayton, 3168 ph: 03 9594 6666

Rosebud Hospital 
1527 Point Nepean Rd, Rosebud, 3939 ph: 03 5986 0666

Sandringham & District Memorial Hospital 
193 Bluff Rd, Sandringham, 3191 ph: 03 9921 1000

Sunshine Hospital 
176 Furlong Rd, St Albans, 3021 ph: 03 8345 1333

The Northern Hospital 
185 Cooper St, Epping, 3076 ph: 03 9219 8000

The Royal Women’s Hospital 
Cnr Flemington Rd, Grattan St, Parkville, 3052 ph: 03 8345 2000

Werribee Mercy Hospital 
300 Princes Hwy, Werribee, 3030 ph: 03 9216 8888

Private hospital

You may choose a private obstetrician to care for you in a private hospital. During the labour and birth, you will be cared for by the hospital midwives. Your obstetrician will attend at crucial points during your labour and will plan to attend the birth. Midwives often work with private obstetricians and assist with appointments and education. Out of pocket expenses vary depending on your level of private health cover and the obstetrician’s fees. It is best to phone your individual health fund and ask them the level of cover you have, including things like anaesthetics and ceasareans.

MAMA Midwives are able to do shared care with some private obstetricians, and provide labour & birth support at home and in the private hospital, no matter where you choose to birth! Book an appointment at the top of the screen to find out more!

Knox Private Hospital 
262 Mountain Hwy, Wantirna, 3152 ph: 03 9210 7000

Masada Private Hospital 26 Balaclava Rd, East St Kilda, 3183 ph: (03) 9038 1300

Mercy Hospital for Women  
163 Studley Rd, Heidelberg, 3084 ph: 03 8458 4444

Mitcham Private Hospital 
27 Doncaster East Rd, Mitcham, 3032 ph: 03 9210 3222

Monash Medical Centre 
Centre Rd, East Bentleigh, 3165 ph: 03 9928 8780

Northpark Private Hospital 
Cnr Plenty, Greenhills Rd, Bundoora, 3083 ph: 03 9467 6022

Peninsula Private Hospital 
49 McClelland Dve, Frankston, 3199 ph: 03 9788 3466

Rosebud Hospital 
1527 Point Nepean Rd, Rosebud, 3939 ph: 03 5986 0666

Sandringham & District Memorial Hospital 
193 Bluff Rd, Sandringham, 3191 ph: 03 9921 1000

South Eastern Private Hospital 
Heatherton Rd & Princes Hwy, Noble Park, 3174 ph: 03 9549 6555

St John of God Heath Care Berwick 
1 Gibb St, Berwick, 3806 ph: 03 9707 1900

St Vincent’s & Mercy Private Hospital 
59-61 Victoria Pde, Fitzroy, 3065 ph: 03 9411 7111

Sunshine Hospital 
176 Furlong Rd, St Albans, 3021 ph: 03 8345 1333

The Bays Hospital 
Vale St, Mornington, 3931 ph: 03 5975 2009

The Northern Hospital 
185 Cooper St, Epping, 3076 ph: 03 9219 8000

The Royal Women’s Hospital 
Cnr Flemington Rd, Grattan St, Parkville, 3052 ph: 03 8345 2000

Waverley Private Hospital 
347 Blackburn Rd, Mt Waverley, 3149 ph: 03 9881 7700

Werribee Mercy Hospital 
300 Princes Hwy, Werribee, 3030 ph: 03 9216 8888

Home – Midwife/private care

A private midwife of your choice is able to care for you throughout your pregnancy, labour and post birth. Out of pocket expenses for a home birth are usually $5000-$7000. Some private insurance companies provide cover of up to $2500 for midwifery care. Medicare is now available for antenatal and postnatal appointments if you see ‘endorsed’ midwives (MAMA midwives are all endorsed). The Cochrane Review (Olsen & Jewell, 2001) states that all women who have a low risk pregnancy should be given the option to choose a home birth.

Book an appointment with a MAMA midwife at the top of the screen or by phoning 9376 7474 to find out more about how we can care for you!

Home – Public hospital care

Two public hospitals offer home birth services to low risk women; Sunshine hospital and Casey hospital ( a division of Monash Medical Centre). You must meet strict hospital criteria to be accepted in these programs. For more information contact the individual hospital.

Sunshine Hospital 
176 Furlong Rd, St Albans, 3021 ph: 03 8345 1333

Monash Medical Centre Clayton 
246 Clayton Rd, Clayton, 3168 ph: 03 9594 6666

How does a private midwife work?

A midwife can work as your primary carer or alongside other caregivers you have chosen to support you. The different combinations of caregivers are called ‘models of care.’ The World Health Organisation states that midwives are the most appropriate primary carer for women with a normal pregnancy and birth (WHO, 1996).

Furthermore, it is well documented in the literature that midwives improve the short and long term mental and physical health outcomes of the mother and baby both in normal pregnancy and birth, and in collaboration with medical assistance in situations where complications arise.

MAMA Midwives can offer care for you in accordance with the following models:

During pregnancy/antenatal care

  • Primary care by a midwife
  • Shared care by a midwife and a public hospital
  • Shared care by a midwife and a private obstetrician
  • Additional care by a midwife (whether you have chosen the public or private system)

Throughout labour and birth

  • Hospital support by a midwife in the public system
  • Hospital support by a midwife in the private system
  • Homebirth with a midwife as primary carer

In early parenting/postnatal care

  • Postnatal care by a midwife in your home
  • Postnatal care by a midwife in our centre
  • 6 week check up for you and your baby
  • Lactation consultation


What is a midwife and how could they help me?

The term midwife means ‘with woman’. Midwives act as partners to women throughout pregnancy, labour, birth and the early postnatal period, providing individualised education, advice and support.

Midwives advocate measures throughout pregnancy and labour which promote natural birth, and are experienced in caring for mother and baby under normal birth conditions. They are also trained to recognise and assist with scenarios that are out of the norm. This includes detection of complications for the mother or baby, requesting medical opinions and carrying out emergency measures if necessary.

Midwives aim for only necessary intervention in the birth process. Midwives can work in a complementary relationship with obstetricians, who are specialists in complicated pregnancy and birth, and in surgery. Midwives can refer women to obstetricians or other appropriate medical practitioners when the client requires care that falls out of the midwives’ scope of practice.

Their role extends to caring for the newborn and assisting with breastfeeding. Research shows that continuity of midwifery care from early pregnancy to around 6 weeks after birth improves short and long term mental and physical health outcomes for mothers and babies.

You can read more about this in the below paper and article:

Sometimes this continuity is achieved by working in small group practices; this is how the MAMA midwives work.

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