OBJECTIVES:To evaluate implementation and outcomes of the Aboriginal Family Birthing Program (AFBP), which provides culturally competent antenatal, intrapartum and early postnatal care for Aboriginal families across South Australia (SA). METHODS:Analysis of births to Aboriginal women in SA 2010-2012; interviews with health professionals and AFBP clients. RESULTS:Around a third of all Aboriginal women giving birth in SA 2010-2012 (n=486) attended AFBP services. AFBP women were more likely to be more socially disadvantaged, have poorer pregnancy health and to have inadequate numbers of antenatal visits than Aboriginal women attending other services. Even with greater social disadvantage and higher clinical complexity, pregnancy outcomes were similar for AFBP and other Aboriginal women. Interviews with 107 health professionals (including 20 Aboriginal Maternal and Infant Care (AMIC) workers) indicated differing levels of commitment to the model, with some lack of clarity about AMIC workers and midwives roles. Interviews with 20 AFBP clients showed they highly valued care from another Aboriginal woman. CONCLUSIONS:Despite challenges, the AFBP reaches out to women with the greatest need, providing culturally appropriate, effective care through partnerships. Implications for Public Health: Programs like the AFBP need to be expanded and supported to improve maternal and child health outcomes for Aboriginal families.

Background Australian and New Zealand clinical practice guidelines, endorsed by the NHMRC in 2010, recommend administration of antenatal magnesium sulphate to women at risk of imminent preterm birth at less than 30 weeks' gestation to reduce the risk of their very preterm babies dying or having cerebral palsy. The purpose of the ongoing W orking to I mprove S urvival and H ealth for babies born very preterm ( WISH ) implementation project is to monitor and improve the uptake of this neuroprotective therapy across Australia and New Zealand. Aims To quantify and explore reasons for nonreceipt of antenatal magnesium sulphate at the Women's and Children's Hospital, in Adelaide, South Australia. Materials and Methods Data from the case records of women who gave birth between 23 +0 and 29 +6 weeks' gestation from 2010 to mid‐2013 were reviewed to determine the proportion of eligible mothers not receiving antenatal magnesium sulphate and to explore reason(s) for nonreceipt over this time period. Results There was a reduction in the proportion of eligible mothers not receiving antenatal magnesium sulphate from 2010 (69.7%) to 2011 (26.9%), which was maintained in 2012 and 2013 (22.5%). In 2012–2013, nonreceipt was predominantly associated with immediately imminent (advanced labour, rapid progression of labour) or indicated emergent birth (actual or suspected maternal or fetal compromise). Conclusions Use of antenatal magnesium sulphate at the Women's and Children's Hospital is now predominantly in‐line with the binational guideline recommendations. Ongoing education and enhanced familiarity with procedures may facilitate timely administration in the context of some precipitous or immediately imminent births.

Introduction . Little is known about women’s views relating to a diagnosis of borderline gestational diabetes mellitus (GDM) and the subsequent management. This study aimed to explore women’s experiences after being diagnosed with borderline GDM, their attitudes about treatment, and factors important to them for achieving any lifestyle changes. Methods . We conducted face-to-face, semistructured interviews with women diagnosed with borderline GDM. Results . A total of 22 women were interviewed. After a diagnosis of borderline GDM, 14 (64%) women reported not being concerned or worried. Management of borderline GDM was thought by 21 (95%) women to be very important or important. Eighteen (82%) women planned to improve their diet and/or exercise to manage their borderline GDM. The most frequently mentioned enabler for achieving intended lifestyle change was being more motivated to improve the health of their baby and/or themselves (15 women). The most frequent barrier was tiredness and/or being physically unwell (11 women). Conclusions . A diagnosis of borderline GDM caused some concern to one-third of women interviewed. The majority of women believed managing their borderline GDM was important and they planned to improve their lifestyle. Women’s own and their babies’ future health were powerful motivators for lifestyle change.

BackgroundThyroid dysfunction pre-pregnancy and during pregnancy (both hyper- and hypothyroidism) is associated with increased risk of adverse outcomes for mothers and infants in the short-and long-term. Managing the thyroid dysfunction (e.g. thyroxine for hypothyroidism, or antithyroid medication for hyperthyroidism) may improve outcomes. The best method of screening to identify and subsequently manage thyroid dysfunction pre-pregnancy and during pregnancy is unknown.ObjectivesTo assess the effects of different screening methods (and subsequent management) for thyroid dysfunction pre-pregnancy and during pregnancy on maternal and infant outcomes.Search methodsWe searched the Cochrane Pregnancy and Childbirth Group's Trials Register (14 July 2015) and reference lists of retrieved studies.Selection criteriaRandomised or quasi-randomised controlled trials, comparing any screening method (e.g. tool, program, guideline/protocol) for detecting thyroid dysfunction (including hypothyroidism, hyperthyroidism, and/or thyroid autoimmunity) pre-pregnancy or during pregnancy with no screening, or alternative screening methods.Data collection and analysisTwo review authors independently assessed eligibility of studies, extracted and checked data accuracy, and assessed the risk of bias of included studies.Main resultsWe included two randomised controlled trials (involving 26,408 women) - these trials were considered to be at low risk of bias.Universal screening (screening all women) versus case finding (screening only those at perceived increased risk) in pregnancy for thyroid dysfunctionOne trial (4562 women) compared universal screening with case finding for thyroid dysfunction. Before 11 weeks' gestation, women in the universal screening group, and 'high-risk' women in the case finding group had their sera tested for TSH (thyroid stimulating hormone), fT4 (free thyroxine) and TPO-Ab (thyroid peroxidase antibody); women with hypothyroidism (TSH > 2.5 mIU/litre) received levothyroxine; women with hyperthyroidism (undetectable TSH and elevated fT4) received antithyroid medication.In regards to this review's primary outcomes, compared with the case finding group, more women in the universal screening group were diagnosed with hypothyroidism (risk ratio (RR) 3.15, 95% confidence interval (CI) 1.91 to 5.20; 4562 women; GRADE: high quality evidence), with a trend towards more women being diagnosed with hyperthyroidism (RR 4.50, 95% CI 0.97 to 20.82; 4562 women; P = 0.05; GRADE: moderate quality evidence). No clear differences were seen in the risks of pre-eclampsia (RR 0.87, 95% CI 0.64 to 1.18; 4516 women; GRADE: moderate quality evidence), or preterm birth (RR 0.99, 95% CI 0.80 to 1.24; 4516 women; GRADE: high quality evidence) between groups. This trial did not report on neurosensory disability for the infant as a child.Considering this review's secondary outcomes, more women in the universal screening group received pharmacological treatment for thyroid dysfunction (RR 3.15, 95% CI 1.91 to 5.20; 4562 women). No clear differences between groups were observed for miscarriage (RR 0.90, 95% CI 0.68 to 1.19; 4516 women; GRADE: moderate quality evidence), fetal and neonatal death (RR 0.92, 95% CI 0.42 to 2.02; 4516 infants; GRADE: moderate quality evidence), or other secondary outcomes: pregnancy-induced hypertension, gestational diabetes, congestive heart failure, thyroid storm, mode of birth (caesarean section), preterm labour, placental abruption, respiratory distress syndrome, low birthweight, neonatal intensive care unit admission, or other congenital malformations. The trial did not report on a number of outcomes including adverse effects associated with the intervention.Universal screening versus no screening in pregnancy for hypothyroidismOne trial (21,846 women) compared universal screening with no screening for hypothyroidism. Before 15 + 6 weeks' gestation, women in the universal screening group had their sera tested; women who screened 'positive' (TSH > 97.5th percentile, fT4 < 2.5th percentile, or both) received levothyroxine.Considering primary review outcomes, compared with the no screening group, more women in the universal screening screened 'positive' for hypothyroidism (RR 998.18, 95% CI 62.36 to 15,978.48; 21,839 women; GRADE: high quality evidence). No data were provided for the outcome pre-eclampsia, and for preterm birth, the trial reported rates of 5.6% and 7.9% for the screening and no screening groups respectively (it was unclear if these percentages related to the entire cohort or women who screened positive). No clear difference was seen for neurosensory disability for the infant as a child (three-year follow-up IQ score < 85) (RR 0.85, 95% CI 0.60 to 1.22; 794 infants; GRADE: moderate quality evidence).More women in the universal screening group received pharmacological treatment for thyroid dysfunction (RR 1102.90, 95% CI 69.07 to 17,610.46; 1050 women); 10% had their dose lowered because of low TSH, high fT4 or minor side effects. No clear differences were observed for other secondary outcomes, including developmental delay/intellectual impairment at three years. Most of our secondary outcomes, including miscarriage, fetal or neonatal death were not reported.Authors' conclusionsBased on the existing evidence, though universal screening for thyroid dysfunction in pregnancy increases the number of women diagnosed with hypothyroidism who can be subsequently treated, it does not clearly impact (benefit or harm) maternal and infant outcomes.While universal screening versus case finding for thyroid dysfunction increased diagnosis and subsequent treatment, we found no clear differences for the primary outcomes: pre-eclampsia or preterm birth. No clear differences were seen for secondary outcomes, including miscarriage and fetal or neonatal death; data were lacking for the primary outcome: neurosensory disability for the infant as a child, and for many secondary outcomes. Though universal screening versus no screening for hypothyroidism similarly increased diagnosis and subsequent treatment, no clear difference was seen for the primary outcome: neurosensory disability for the infant as a child (IQ < 85 at three years); data were lacking for the other primary outcomes: pre-eclampsia and preterm birth, and for the majority of secondary outcomes.For outcomes assessed using the GRADE approach the evidence was considered to be moderate or high quality, with any downgrading of the evidence based on the presence of wide confidence intervals crossing the line of no effect.More evidence is needed to assess the benefits or harms of different screening methods for thyroid dysfunction in pregnancy, on maternal, infant and child health outcomes. Future trials should assess impacts on use of health services and costs, and be adequately powered to evaluate the effects on short- and long-term outcomes.

Background: Strong evidence supports administration of magnesium sulphate prior to birth at less than 30 weeks' gestation to prevent very preterm babies dying or developing cerebral palsy. This study was undertaken as part of The WISH (Working to Improve Survival and Health for babies born very preterm) Project, to assess health professionals' self-reported use of antenatal magnesium sulphate, and barriers and enablers to implementation of 2010 Australian and New Zealand clinical practice guidelines.Methods: Semi-structured, one-to-one interviews were conducted with obstetric and neonatal consultants and trainees, and midwives in 2011 (n = 24) and 2012-2013 (n = 21) at the Women's and Children's Hospital, South Australia. Transcribed interview data were coded using the Theoretical Domains Framework (describing 14 domains related to behaviour change) for analysis of barriers and enablers.Results: In 2012-13, health professionals more often reported 'routinely' or 'sometimes' administering or advising their colleagues to administer magnesium sulphate for fetal neuroprotection (86 % in 2012-13 vs. 46 % in 2011). 'Knowledge and skills', 'memory, attention and decision processes', 'environmental context and resources', 'beliefs about consequences' and 'social influences' were key domains identified in the barrier and enabler analysis. Perceived barriers were the complex administration processes, time pressures, and the unpredictability of preterm birth. Enablers included education for staff and women at risk of very preterm birth, reminders and 'prompts', simplified processes for administration, and influential colleagues.Conclusions: This study has provided valuable data on barriers and enablers to implementing magnesium sulphate for fetal neuroprotection, with implications for designing and modifying future behaviour change strategies, to ensure optimal uptake of this neuroprotective therapy for very preterm infants.

In 2010, the Australian National Health and Medical Research Council (NHMRC) endorsed Australian and New Zealand clinical practice guidelines that recommend magnesium sulphate to be given to women at risk of imminent, very early preterm birth (at less than 30 weeks gestation) for the prevention of death and cerebral palsy in their infants (The Antenatal Magnesium Sulphate for Neuroprotection Guideline Development Panel 2010). Now, the WISH Project (Working to Improve Survival and Health of babies born preterm), supported by the Cerebral Palsy Alliance, is working to bring Australian and New Zealand clinical practice in line with the recommendations from these guidelines (ARCH 2013).

Health professionals at 25 Australian and New Zealand tertiary maternity hospitals were surveyed about local implementation of a clinical practice guideline for antenatal magnesium sulphate for fetal neuroprotection. Seventy-six percent of respondents reported that their hospital is currently following a guideline; 36% confirmed that their hospital is auditing uptake. Estimates of uptake ranged from 53 to 90%. Ongoing education and support are needed to ensure that the guidelines are optimally implemented, and uptake and important health outcomes are monitored.

BACKGROUND:Babies born very preterm (before 30 weeks gestation) are at high risk of dying in their first weeks of life, and those who survive are at risk of developing cerebral palsy in childhood. Recent high-quality evidence has shown that giving women magnesium sulphate immediately prior to very early birth can significantly increase the chances of their babies surviving free of cerebral palsy. In 2010 Australian and New Zealand clinical practice guidelines recommended this therapy. The WISH (Working to Improve Survival and Health for babies born very preterm) Project aims to bi-nationally improve and monitor the use of this therapy to reduce the risk of very preterm babies dying or having cerebral palsy.METHODS/DESIGN:The WISH Project is a prospective cohort study. The 25 Australian and New Zealand tertiary level maternity hospitals will be provided with a package of active implementation strategies to guide the introduction and local adaptation of guideline recommendations. Surveys will be conducted at individual hospitals to evaluate outcomes related to local implementation progress and the use and value of the WISH implementation strategies. For the hospitals participating in the 'WISH audit of uptake and health outcomes data collection', the primary health outcomes (assessed through case note review, and 24 month corrected age questionnaires) will be: the proportion of eligible women receiving antenatal magnesium sulphate; and rates of death prior to primary hospital discharge and cerebral palsy at two years corrected age in infants born to eligible mothers. For hospitals wishing to assess factors influencing translation locally, barriers and facilitators will be measured through interviews with health care professionals, to further guide implementation strategies. Study outcomes for the early phase of the project (Year 1) will be compared with the later intervention phase (Years 2 and 3).DISCUSSION:The WISH Project will offer insight into the effectiveness of a multifaceted implementation strategy to improve the uptake of a novel neuroprotective therapy in obstetric clinical practice. The successful implementation of antenatal magnesium sulphate for fetal neuroprotection in Australia and New Zealand could lead to over 90 fewer very preterm babies dying or suffering the long-term consequences of cerebral palsy each year.

BACKGROUND The number of pathology tests ordered by general practitioners is rising. Some of this increase may reflect overtesting, overutilisation or training deficiency. The aim of this study was to identify the pathology training needs of general practice registrars in regards to test ordering and interpretation of common conditions found in general practice. METHODS A pathology training needs assessment survey was distributed to 82 South Australian general practice registrars. RESULTS The survey response rate was 55%. Pathology training diminishes as participants move through their medical training. General practice registrars had most difficulty with test ordering and interpretation in the areas of fatigue, menopausal complaints, arthritis and menstrual problems. DISCUSSION These findings will assist those who supervise and support general practice registrars in their training. Targeted pathology training in areas identified as difficult may assist in reducing healthcare expenditure and improve the management of patients' clinical conditions.

The aim of this individual participant data (IPD) meta-analysis is to assess whether the effects of repeat prenatal corticosteroid treatment given to women at risk of preterm birth to benefit their babies are modified in a clinically meaningful way by factors related to the women or the trial protocol.

Although many maternal deaths are preventable, health of mothers has been a much neglected issue especially in low income countries (Cook 2004; DFID 2011a). In the recent past, more than 350,000 women have died each year from preventable complications related to pregnancy and childbirth (Ki-Moon 2010). Almost all (99%) maternal deaths continue to occur in poorly resourced countries, with 225 deaths per 100,000 livebirths occurring in low to middle income countries (LMICs) compared with 18 deaths per 100,000 livebirths in high income countries in 2011 (Lozano 2011). Achieving Millennium Development Goal 5 (MDG5) - to reduce maternal mortality by 75% between 1990 and 2015 - will require an annual decline in mortality of 5.5% (Wilmoth 2010). Although methods for estimating maternal deaths are acknowledged to be weak (Wilmoth 2010), all recent estimates show maternal deaths to be declining. There has been a one-third drop from 409,100 maternal deaths in 1990 to 273,500 deaths in 2011 (Lozano 2011). This current rate of decline clearly will not be sufficient to meet the overall MDG5 target by 2015 – a mere three years away. A maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration, the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes (WHO 1993). A maternal near-miss case is where a woman nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of the termination of the pregnancy (Say 2009). Common life-threatening complications include severe postpartum haemorrhage, severe pre-eclampsia, eclampsia, sepsis/severe systemic infection, and ruptured uterus (WHO 2011a). The main causes of maternal death are haemorrhage, infection, obstructed labour and complications of unsafe abortion (Khan 2006). Many of these causes have a link with nutrition, and may even reach back to before the woman's own birth (Rush 2000). For example, severe anaemia is linked to deaths from complications such as postpartum haemorrhage and short stature of mothers may lead to obstructed labour. In many low income countries, diets are often based on cereals or legumes, with little variety, few animal products and a restricted range of fruits and vegetables (Ladipo 2000). Over 40% of the world's pregnant women have anaemia, with 90% living in Africa or Asia (Sanghvi 2010). Women with anaemia typically have deficiencies of many other nutrients such as iodine, vitamin A, and zinc that can lead to greater morbidity and mortality for both mother and child (Black 2008, Shankar 2009, van den Broek 2003). Many life-threatening or serious events/morbidities in pregnant women may be amenable to nutrition interventions (Christian 2002). Ideally many of these interventions would have a preventive focus e.g. iron supplementation, food fortification or dietary diversification to decrease the incidence of anaemia in women before they become pregnant. Some of potentially effective solutions such as supplementation may seem straightforward to implement, but the reality of achieving health gains is very complex. There are many access, contextual, behavioural and system barriers to implementation of nutritional programs for women of reproductive age. One fundamental cause of pregnant women and other women of reproductive age being undernourished is poverty which leads to a limited ability to purchase and consume sufficient and/or suitable food. Discrimination against women and girls which restricts their access to food (Gittlesohn 1997) and health care, lack of quality antenatal care, and cultural and social beliefs and practices such as ‘eating down’ to avoid giving birth to a large baby, may also contribute to undernourishment (Nag 1994). Nutrition interventions or other interventions aimed at improving women's nutritional status may work directly to improve maternal survival by preventing or treating disease, infections or nutritional deficiencies; by improving immune status; or by improving healthcare seeking behaviour including the use of quality antenatal, intrapartum and postnatal care. Early nutritional interventions may influence growth of young women and girls and thus reduce the incidence of obstructed labour, specifically when due to cephalopelvic disproportion. Improved nutrition may lessen fatigue and also improve women's emotional wellbeing. Fetal, neonatal and infant survival and health is closely related to maternal nutrition: deficiencies in key micronutrients such as folate can lead to serious congenital birth defects, and intra-uterine growth retardation, which can result from poor maternal nutrition, can lead to low birth weight in newborns (Kramer 1987). Therefore, the prevention and reduction of maternal undernutrition is vital for ensuring fetal, neonatal and infant health and survival. A long-term aim would be for all women to enter pregnancy in an adequately nourished state. Almost one third of adolescent girls in low-middle income countries are married and conceive within a year of marriage (WHO 2011b); in sub-Saharan Africa, nearly two-thirds of women have their first child before the age of 20 years (Bongaarts 1998). Clearly, intergenerational perspectives and activities are required to break the cycles of poverty and malnutrition and ensure that women are well nourished at all stages of life. It is likely that single nutritional interventions will need to be supported by other strategies in order to be effective on a broad scale. However nutrition programs have not always been well integrated with maternal and child health (MCH) programs and “there is an emerging international consensus that the convergence of nutrition and MCH is essential” (Streatfield 2008, p.238). There are many impediments to the implementation of effective interventions, particularly in poor countries. Some important considerations are access to food (physical, social, economic and cultural access); workforce availability and retention and program transferability and sustainability; weak health systems; and policy barriers (Zehner 2009). The effectiveness of nutritional interventions at improving nutritional and health status among females of reproductive age and pregnant and lactating women in LMICs depends on several overlapping factors ranging from cost of food and availability of a diversity of foods, to broader factors associated with social and political structures. Underlying chronic conditions can also affect a woman's ability to adequately absorb nutrients and diseases such as HIV/AIDS and malaria can also lead to serious nutritional deficiencies and severely compromised immune systems. Many interventions (household, community or facility based) have been used to address the poor nutritional status of women, including provision of food directly or improved access to the means to produce food or purchase food such as through voucher systems or cash transfers; macronutrient and micronutrient supplementation; nutritional advice and counselling; and preventing and treating diseases which adversely affect nutritional status. Successful interventions can not only improve a woman's nutritional status but can also decrease maternal morbidity and mortality. Ideally each woman would enter pregnancy in a well-nourished state but this may be largely dependent on the nutritional status of one's own mother and whether or not a woman has been adequately nourished throughout her whole life, including during the prenatal months. Evidence suggests that poor nutrition in the womb can lead to long-term, chronic health problems (Barker, 1997). An intergenerational perspective is therefore crucial. There are many pathways to improving women's nutrition – and many barriers which hinder the ability of nutritional interventions to prevent maternal morbidity and mortality. These are outlined in the logic model/conceptual framework (Anderson 2011) shown in Figure 1. The factors that reduce program effectiveness are complex and relate to issues as diverse as distribution failures and lack of adherence (women are unwilling or unable to adhere in the short or longer term). This illustrates the importance of understanding the processes of implementation and the reasons for sustainability of improved outcomes, which may well differ between contexts. Every two minutes around the world there is a maternal death– and one woman dies every seven minutes from postpartum haemorrhage, the single most common cause of maternal mortality (Potts 2010). It is therefore important to synthesise the evidence about the effects of interventions to prevent maternal deaths and reduce maternal morbidities. In this review we will present the evidence about the potential of nutritional interventions or interventions to change nutritional status in women of reproductive age in making an impact on maternal mortality and morbidity. Maternal mortality and morbidity are the main focus of the review. Maternal mortality and morbidity are also inextricably linked with stillbirth and neonatal deaths and there have been recent calls for health systems to deliver more effectively for both mothers and babies (Pattinson 2011). Pregnancy outcomes are important in their own right, and also as an indicator of maternal health due to problems in accurately measuring maternal mortality prevalence (maternal mortality is usually measured in terms of prevalence rates per 100,000 live births, requiring very large sample datasets for precise estimates) or self-reported morbidity. Pregnancy outcomes will therefore also be included in this review. There are systematic reviews that examine maternal and child health impacts of some nutrition interventions such as iron supplementation (Fernández-Gaxiola 2011) and magnesium sulphate supplementation (Duley 2003), and agricultural interventions such as home gardens (Masset 2012). Our proposed review is the only one that we are aware of that encompasses such a wide scope in terms of target population and breadth of the various interventions. This review will synthesise the evidence about which programs are likely to successfully influence maternal nutrition and therefore lead to improvements in maternal mortality and morbidity. It also aims to outline what is necessary to implement effective programs and interventions and will therefore aim to be highly relevant for both policy and practice. Main objective: To assess the effects of nutrition interventions or programs or those directed at influencing maternal nutritional status (nutrition-sensitive interventions/programs) on maternal mortality and serious maternal morbidities. Additional questions and objectives: In Table 1 we have expanded the objectives into study design, participants, interventions and outcomes to clarify the scope of the review. We will report the effects of the nutrition component separately wherever possible. We plan to contact study authors to request these data if not available in study publications. Comparators will be standard care or no program/intervention or delayed intervention, or different types of nutrition program or package. Interventions may occur during pregnancy and/or lactation, pre-pregnancy or inter-pregnancy. Studies of various designs addressing the effects of the nutrition interventions on maternal, fetal and neonatal outcomes of interest as well as studies evaluating implementation of these interventions will be considered for inclusion, along with qualitative studies that address reasons for adherence or lack of uptake of these interventions. Randomised controlled trials (including cluster trials), other controlled trials, or observational cohort studies without controls, interrupted time series, case-control and cross-sectional studies will be included in synthesis of effects. Qualitative studies (reporting surveys or interviews) will be included where they report on primary evidence and address behaviours such as adherence, or report information on barriers and enablers, and/or factors affecting scaling up or sustainability of programs. Relevant qualitative information will also be collected from studies providing quantitative data. We will not use any methodology inclusion criteria to screen qualitative evidence; all studies reporting evidence will be included in this analysis. We will, however, critically appraise this evidence using explicit criteria (see Methods below). We will use the cited references feature in Web of Science and Scopus. We will also search the following regional databases: #x2028;○ African Index Medicus, LILACS, CBM, Australasian Medical Index, IndMED, KoreaMed, IMSEAR, WPRIM. A search strategy for MEDLINE is attached (see Appendix). This strategy will be adapted for the other databases listed above. We will also search Google and Google Scholar using terms such as “Millennium Development Goal 5”, “MDG5”, “maternal mortality and nutrition”, “safe motherhood”, “essential nutrition actions” and we will also use the cited references feature in Google Scholar. Search dates will be from 1990 to present. We will scan 2011 and 2012 issues of journals likely to publish relevant studies, including Food Nutrition Bulletin and Maternal Child Nutrition. We will search reference lists of potentially eligible studies and systematic reviews addressing our interventions of interest. We will contact key authors publishing in the area of maternal nutrition. No language or publication status restrictions will be applied. We will attempt to obtain translations where possible if the review team is unable to translate particular papers. Potential study eligibility will be independently assessed through a two-level process. At least two review authors will apply the predefined screening criteria (see Appendices 1 and 2). Any studies considered obviously irrelevant from screening the titles and/or abstracts will be excluded at the first level. Any uncertainties at the first level screening will be re-assessed on the basis of full text in the second level of screening. We will also contact the primary authors of the study for any insufficient or unclear information if required. Any disagreement will be solved by discussion. If needed, a third review author will be consulted for any unsolved disagreement, and a consensus will be sought. Reasons for exclusion of studies will be documented. Data from the included studies will be independently coded and extracted by at least two review authors using the predefined data extraction forms (see appendices 3, 4 and 5). If there are two or more papers describing the same study, they will be combined and coded as a single study. A third review author will be consulted in the event of any disagreements, and consensus will be sought. We will attempt to contact authors of the original reports to obtain further details if required. We will extract frequency for the binary outcomes, and mean with standard deviation for the continuous outcomes. The adjusted effect sizes will be also collected for observational studies if possible. The pre-post change effect sizes will be extracted for the interrupted time series and before-and-after studies. For qualitative findings, we plan to extract all themes or qualitative information identified in the primary studies and relevant to the research questions. Extraction of qualitative data will be driven by a theoretical framework of behaviour change and motivation (Michie 2011). References will be managed using EndNote X4 (Thomson Reuters, USA 2010). We will use RevMan 5 (Nordic Cochrane Centre, Cochrane Collaboration 2011) to prepare our review and we plan to use SAS 9.3 (SAS Institute Inc, USA 2011) for any meta-regression analyses. We will use Microsoft Excel to conduct synthesis of qualitative information. Two review authors will independently assess quality of studies and risk of bias for each study. The quality of the quantitative studies and qualitative studies will be separately assessed using different approaches. We will use the criteria recommended by the Cochrane Effective Practice and Organization of Care Group1 to assess risk of bias for controlled studies, including randomised controlled trials and non-randomised studies that have a well-defined control group; and the methods outlined by NICE (2009) for other study designs (case control and cohort studies). The risk of potential bias will be assessed as low, high or unclear for each component. We will resolve any disagreement by discussion or by involving a third assessor. The risk of different biases for RCTs and other comparative studies, as outlined in by EPOC, is as follows: • Random sequence generation (checking for possible selection bias) For each included study we will describe the method used to generate the allocation sequence in sufficient detail to allow an assessment of whether it should produce comparable groups. A risk of bias is low for any truly random process (e.g. random number table, computer random number generator), or high for any non-random process (e.g. odd or even date of birth; hospital or clinic record number; assignment based on self-selection by participant or programme planner). • Allocation concealment (checking for possible selection bias) For each included study we will describe the method used to conceal allocation to interventions prior to assignment and will assess whether intervention allocation could have been foreseen in advance of, or during recruitment, or changed after assignment. The risk is low if the allocation methods, such as telephone or central randomisation, consecutively numbered sealed opaque envelopes were used; and high for any open random allocation, unsealed or non-opaque envelopes, alternation, or date of birth. • Baseline outcome measurement (checking for confounding/group equivalence) For each included study we will describe whether outcomes were measured prior to the intervention, and the extent to which important differences were present across study groups. The risk is low if performance or patient outcomes were measured prior to the intervention, and no important differences were present across study groups, or if imbalanced but appropriate adjusted analysis was performed (e.g. analysis of covariance); and high if important differences were present and not adjusted for in analysis, or if no baseline measurement was conducted. • Baseline characteristics (checking for confounding/group equivalence) For each included study we will describe whether baseline characteristics are reported, and the extent to which important differences were present across study groups. The risk is low if baseline characteristics are reported and similar across groups, or if imbalanced but appropriate adjusted analysis was performed; and high if there is no report of characteristics in text or tables or if there are differences between groups which are not accounted for in adjusted analysis. • Blinding of participants and personnel (checking for possible performance bias) For each included study we will describe the methods used, if any, to blind study participants and personnel from knowledge of which intervention a participant received. We will assess blinding separately for different outcomes or classes of outcomes. • Contamination (checking for possible performance bias) For each included study we will describe the likelihood that the control group received the intervention. The risk is low if allocation was by community, institution or practice and it is unlikely that the control group was exposed to the intervention (e.g. control group is geographically separated); and high if allocation was to individual or patient, and it is likely that the control group was exposed to the intervention (e.g. this is particularly likely if the intervention consists solely of information or training). • Blinding of outcome assessment (checking for possible detection bias) For each included study we will describe the methods used, if any, to blind outcome assessors from knowledge of which intervention a participant received. The risk is low for outcomes measured objectively, or, for self-reported or subjectively measured outcomes, if outcome assessors were blinded; and high if outcome assessors were not blinded for self-reported or subjectively measured outcomes. We will assess blinding separately for different outcomes or classes of outcomes. • Losses to follow-up (checking for possible attrition bias) For each included study which includes baseline measurement, we will describe the extent of differential attrition between groups, and whether attrition is likely to bias the assessment of outcomes. The risk is low if attrition is not differential between groups, or is shown to be uncorrelated with risk factors; and high if attrition differs by groups and no evidence is presented to indicate systematic attrition by particular exposure groups. • Selective reporting (checking for reporting bias) For each included study we will describe how we investigated the possibility of selective outcome reporting bias and what we found. Where it is clear that all of the study's pre-specified outcomes and all expected outcomes of interest to the review have been reported, a low risk of bias will be documented. In contrast, the risk of bias will be regarded as high where not all the study's pre-specified outcomes have been reported, or one or more reported primary outcomes were not pre-specified, or outcomes of interest are reported incompletely and so cannot be used fully, or study fails to include results of a key outcome that would have been expected to have been reported. • Overall risk of bias We will make explicit judgements about whether studies are at high risk of bias, according to the criteria given in the Cochrane Handbook (Higgins 2011). We will assess the likely magnitude and direction of the bias and whether we consider it is likely to impact on the findings. We will explore the impact of the level of bias through undertaking sensitivity analyses if needed. if there were sufficient data points to enable reliable statistical inference and a formal test for trend was used (requires at least 3 points recorded pre and post-intervention, and either a repeated measures analysis being performed or ANOVA or multiple t-test being used and at least 30 observations per data point). • Correlation between intervention and data collection (checking detection bias) if the intervention itself was unlikely to affect data collection, e.g. sources and methods of data collection were identical before and after intervention. • Blinding assessment of primary outcomes if clearly described in the original paper that the primary outcome variables had been assessed blindly or they were objective, such as length of hospital stay, or biochemical indicators (such as iron, haemoglobin, zinc concentrations) as assessed by a standardised test. • Completeness of dataset if dataset covered more than 80% of the total number of participants or episodes of care in the study. Outcome measurement is considered reliable if two or more raters had at least 90% agreement or kappa at 0.8 or more; also if the outcome variables were collected from an automatic system, such as length of hospital stay or values of biochemical indicators. It is however scored “not clear” if reliability was not reported for outcome measures that had been obtained by chart extraction or collected by an individual. Risk ratios and mean difference with 95% confidence intervals will be computed for dichotomous and continuous outcomes, respectively. In the case that a continuous outcome is measured differently among trials, the standardised mean difference may be used to combine trial results. If the data are very sparse, the Peto odds ratio will be used for dichotomous, and Mann-Whitney test for continuous data. For non-randomised studies, we will use adjusted effect sizes or other methods to address potential confounding. If an outcome is measured at multiple time points in a controlled study, we will usually take the measure at longest follow-up. If an outcome is measured at multiple time points in an interrupted time series study, we will compute a summary of effect size for each outcome at each time point separately, taking potential auto-correlation into account. We will include cluster-randomised trials in the analyses along with individually randomised trials. Their sample sizes will be adjusted by the methods described in the Cochrane Handbook (Higgins 2011) using an estimate of the intracluster correlation coefficient (ICC) derived from the trial (if possible), from a similar trial or from a study of a similar population. If we use ICCs from other sources, we will report this and conduct sensitivity analyses to investigate the effect of variation in the ICC. If we identify both cluster-randomised trials and individually-randomised trials, we plan to synthesise the relevant information. We will consider it reasonable to combine the results from both if there is little heterogeneity between the study designs and the interaction between the effect of intervention and the choice of randomisation unit is considered to be unlikely. We will also acknowledge heterogeneity in the randomisation unit and perform a sensitivity analysis to investigate the effects of the randomisation unit. A statistician will be involved in this part of the analysis. For each included study, and for each outcome or class of outcomes, we will describe the completeness of data including attrition and exclusions from the analysis. We will state whether attrition and exclusions were reported and the numbers included in the analysis at each stage (compared with the total randomized participants), reasons for attrition or exclusion where reported, and whether missing data were balanced across groups or were related to outcomes. Where sufficient information is reported, or can be supplied by the trial authors, we will re-include missing data in the analyses which we undertake. The risk of bias will be regarded as low if there were no missing outcome data or missing outcome data were balanced across groups; and high for any numbers or reasons for missing data imbalanced across groups, “as treated” analysis done with substantial departure of intervention received from that assigned at randomisation. As the review will include both quantitative and qualitative data, we propose a mixed design and mixed methods systematic review. A mixed-methods model is an appropriate way to address several research questions in the same systematic review. The review aims not only to address whether the nutrition interventions are effective, but to also explore more qualitatively why effects of interventions vary by setting and of possible approaches to overcome the barriers and increase the enablers of their implementation. The qualitative component will help extend the review by reporting evidence from qualitative studies or qualitative component of quantitative studies to address important aspects other than effectiveness including implementations, up-scaling, transferability and sustainability of the nutrition interventions. We will use the principles and methods of the Campbell and Cochrane Collaborations (Higgins 2011) integrated with evaluation of program impact, context (setting, population characteristics, feasibility, sustainability, scalability) and analysis of barriers and enablers. For interventional studies, we will conduct random-effects meta-analyses with an inverse variance weight when it is sensible to combine studies (clinical or statistical heterogeneity is not of high concern). The random-effects summary will be treated as the average range of possible treatment effects and we will discuss the clinical implications of treatment effects differing between trials. The results will be then presented as the average treatment effect with 95% confidence intervals, and the estimates of T2 and I2. If not appropriate to conduct meta-analyses and/or synthesise effect sizes, we plan to report review findings in tabular and narrative form. We will report separate estimates of the intervention effects by study design. Findings of randomised studies will be presented separately for those of prospective cohort studies and of interrupted time series and cross-sectional studies. Given the low incidence rates of the primary outcomes, we also plan to conduct power analysis, both of the individual studies and for the meta-analyses. If the meta-analysis could not be carried out, we plan to report forest plots together with an assessment of statistical power in the narrative review. A cross-design synthesis will be considered only when sufficiently large number of studies included in the review might allow univariate and multivariate exploration of why differences in results might emerge from different study designs. In this situation, the assumptions underlying the comparison will be made explicit, and the possibility of design-related differences in effects will be critically examined. If we obtain sufficient included studies and observe any variation in the covariates, a meta-regression using a random effects model will be carried out to identify any relation between the observed variables and the heterogeneity. We will assess statistical heterogeneity in each meta-analysis using the T2, I2 and Chi2 statistics. We will regard heterogeneity as substantial if I2 is greater than 30% and either T2 is greater than zero, or there is a low P value (less than 0.10) in the Chi2 test for heterogeneity. The primary outcomes will be used in subgroup analysis. For meta-analyses using methods other than inverse variance, we will assess differences between subgroups by inspection of the subgroups' confidence intervals (non-overlapping confidence intervals indicate a statistically significant difference in treatment effect between the subgroups) or we will apply interaction tests if possible. The potential effects of biases on the quality of the included trials will be assessed by sensitivity analysis. We will exclude the high-bias studies from the analysis to identify whether there are any substantive differences to the pooled result. The sensitivity analyses will be carried out to explore statistical heterogeneity and the effects of any assumptions made such as the value of the ICC used for cluster-randomized trials. If there are 10 or more studies in a meta-analysis we will investigate reporting biases (such as publication bias) using funnel plots. We will assess funnel plot asymmetry visually, and use formal tests for funnel plot asymmetry. If asymmetry is detected in any of these tests or is suggested by a visual assessment, we will perform exploratory analyses to investigate it. For qualitative data, we will use thematic analyses to synthesise qualitative findings through clear identification of prominent themes, and providing organised and structured ways of dealing with a large volume of literature under these themes. Submission of draft review: 15 August 2012 We would like to thank AUSAID for funding this review and for support provided by 3ie and IDCG. 1. Is it original research? 2. Is the intervention related to nutrition? (Nutrition component = provision of supplements/food fortification/food or IEC or increasing access to food or helping prevent/treat conditions such as anaemia). 3. Are outcomes of key interest reported? (Outcomes of key interest = maternal mortality/morbidity; post-intervention changes; information of implementation, up-scaling, transferability and sustainability of the nutrition intervention/program) 4. Are participants girls or women of reproductive age? 5. Are participants from low and middle-income countries or marginalised and/or disadvantaged groups from high-income countries? 6. Is the publication date 1990 or later? Comments: _________________________________________________________________________________ ____________ _________________________________________________________________________________ ________________________ Decision: Exclude Yes/Uncertain: Obtain fulltext for level 2 screening Study information Study settings Participants The Intervention Comparator Types of outcome reported: Primary [__] Secondary [__] Qualitative [__] Primary outcomes 32. Measure of maternal death 33. Primary causes of maternal death 34. Indirect causes of maternal death 35. Measure of serious maternal complications 36. Effect size information 37. Cause of neonatal mortality 38. Changes following the nutrition interventions (9=unspecified) Study design: Other ___________________ Reasons for adherence and uptake of interventions and programs: Barriers and enablers related to implementation, up-scaling, transferability and sustainability of the interventions, including behaviour change and motivation factors (Michie 2011) Potential methods to overcome barriers and increase enablers Strategies used in implementation, up-scaling, transferability and sustainability of the interventions Suggestions to optimise implementation, up-scaling, transferability and sustainability of the interventions Near-miss cases (a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy) - any of the following: ○ Cardiovascular dysfunction (any of: shock, cardiac arrest, use of continuous vasoactive drugs, cardiopulmonary resuscitation, severe hypoperfusion, severe acidosis) ○ Respiratory dysfunction (any of: acute cyanosis, gasping, severe tachypnea, severe bradypnea, intubation and ventilation not related to anaesthesia, severe hypoxemia) ○ Renal dysfunction (any of: non-responsive to fluids or diuretics, dialysis for acute renal failure, severe acute azotemia) ○ Coagulation/haematological dysfunction (any of: failure to form clots, massive transfusion of blood or red cells, severe acute thrombocytopenia) ○ Hepatic dysfunction (any of: jaundice in the presence of pre-eclampsia, severe acute hyperbilirubinemia) ○ Neurological dysfunction (any of: prolonged unconsciousness/coma, stroke, uncontrollable fits/status epilepticus, total paralysis) ○ Uterine dysfunction (any of: uterine haemorrhage or infection leading to hysterectomy) A. MATERNAL MORTALITY AND MORBIDITY 1. Maternal mortality/ [MeSH] 2. Pregnancy complications/ [MeSH] 3. (Severe or serious or acute or fatal or catastrophic or ??) adj3 (mother or maternal or maternity) 4. (Millennium Development Goal adj 5) or MDG5 or MDG-5 or (MDG adj 5) 5. Obstetric adj3 emergenc* 6. 1 or 2 or 3 or 4 or 5 7. Survival rate/ [MeSH] 8. Fatal outcome/ [MeSH] 9. Cause of death/ [MeSH]Anemia/ [MeSH] 10. Infection/ [MeSH] 11. Near adj miss* 12. Life adj3 threat* 13. 7 or 8 or 9 or 10 or 11 or 12 14. (Maternal or mother*) ti.ab or Mothers [MeSH] 15. 13 and 14 B. WOMEN OF REPRODUCTIVE AGE 16. Adolescent [MeSH] OR Young Adult (19-24 yrs) OR Adult (19–44 yrs) with Female check tag] 17. Maternal health services/ 18. Reproductive health.sh.ti.ab 19. Pregnant women [MeSH] 20. Pregnancy in Adolesence [MeSH] 21. Women's health [MeSH] 22. Preconception 23. Preconception care [MeSH} 24. 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 C. NUTRITION 25. Maternal nutritional physiological phenomena [MeSH] 26. Nutrition disorders/ [MeSH] 27. Nutrition status [MeSH] 28. Nutrition policy [MeSH] 29. Nutrition therapy [MeSH] 30. Nutritional requirements [MeSH] 31. Dietary supplements/ [MeSH] 32. Dietary services [MeSH] 33. Vitamins/ [MeSH] 34. Minerals/ [MeSH] 35. Food, fortified [MeSH] 36. Food aid.ti,ab 37. Food supply [MeSH] 38. Multiple micronutrient(s).ti.ab 39. MMN.ti.ab 40. 41. Micronutrients/ [MeSH]Trace elements/ [MeSH] 42. (Undernutrition or undernourish*).ti.abr 43. Eating down.ti.ab 44. 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 or 41 or 42 or 43 45. Breast feeding [MeSH] or (Breastfeed* or breast feed* or breast fed).ti.ab 46. 25 and 45 COMBINING A, B AND C 47. (44 or 45) and 6 48. 46 or 47 48 and (24 or 15) All authors will contribute to applying methods, reviewing and editing content and interpreting results. Philippa Middleton has designed the search strategy and will conduct the searches. Zulfiqar Bhutta, Zohra Lassi, Tran Son Thach and Philippa Middleton will assess study eligibility, extract data, structure the results and produce review drafts. Tran Son Thach will provide statistical expertise, assisted by Philippa Middleton, Zulfiqar Bhutta and Zohra Lassi. Philippa Middleton, Tanya Bubner, Zulfiqar Bhutta, Zohra Lassi, Vicki Flenady and Caroline Crowther will provide expertise in qualitative methods and implementation strategies. All authors have published in the area of maternal nutrition. Professor Bhutta has conducted trials and other studies which may be considered for inclusion in this review. Professor Bhutta and Zohra Lassi are currently conducting or planning trials or studies which may be considered for inclusion in this review. Australian Agency for International Development (AUSAID) Australian Research Centre for Health of Women and Babies (ARCH), Robinson Institute, The University of Adelaide, Australia

OBJECTIVES To describe the development and evaluation of an accreditation program for Point of Care Testing (PoCT) in general practice, which was part of the PoCT in general practice (GP) Trial conducted in 2005-07 and funded by the Australian Government. SETTING AND PARTICIPANTS Thirty general practices based in urban, rural and remote locations across South Australia, New South Wales and Victoria, which were in the intervention arm of the PoCT Trial were part of the accreditation program. A PoCT accreditation working party was established to develop an appropriate accreditation program for PoCT in GP. A multidisciplinary accreditation team was formed consisting of a medical scientist, a general practitioner or practice manager, and a trial team representative. METHODOLOGY AND SEQUENCE OF EVENTS: To enable practices to prepare for accreditation a checklist was developed describing details of the accreditation visit. A guide for surveyors was also developed to assist with accreditation visits. Descriptive analysis of the results of the accreditation process was undertaken. OUTCOMES Evaluation of the accreditation model found that both the surveyors and practice staff found the process straightforward and clear. All practices (i.e. 100%) achieved second-round accreditation. DISCUSSION AND LESSONS LEARNED The accreditation process highlighted the importance of ongoing education and support for practices performing PoCT.

Our aim was to develop a tool to identify specific features of the business and financial management of practices that facilitate better quality care for chronic illness in primary care. Domains of management were identified, resulting in the development of a structured interview tool that was administered in 97 primary care practices in Australia. Interview items were screened and subjected to factor analysis, subscales identified and the overall model fit determined. The instrument's validity was assessed against another measure of quality of care. Analysis provided a four-factor solution containing 21 items, which explained 42.5% of the variance in the total scores. The factors related to administrative processes, human resources, marketing analysis and business development. All scores increased significantly with practice size. The business development subscale and total score were higher for rural practices. There was a significant correlation between the business development subscale and quality of care. The indicators of business and financial management in the final tool appear to be useful predictors of the quality of care. The instrument may help inform policy regarding the structure of general practice and implementation of a systems approach to chronic illness care. It can provide information to practices about areas for further development.

BACKGROUNDPoint-of-care testing is increasingly being used in general practice to assist GPs in their management of patients with chronic disease. However, patient satisfaction and acceptability of point-of-care testing in general practice has not been widely studied.AIMTo determine if patients are more satisfied with point-of-care testing than with pathology laboratory testing for three chronic conditions.DESIGN OF STUDYAs part of a large multicentre, randomised, controlled trial assessing the use of point-of-care testing in Australian general practice, satisfaction was measured for patients having pathology testing performed by point-of-care testing devices or pathology laboratories. Patients in the trial were managed by GPs for diabetes, hyperlipidaemia, and/or anticoagulant therapy.METHODPatient satisfaction was measured using level of agreement with a variety of statements at the end of the study with a patient satisfaction questionnaire for both the intervention and control groups. Analysis was performed using a mixed model analysis of variance (ANOVA) with allowance for clustering at the practice level following Box-Cox transformations of the data to achieve normality.RESULTSOverall, intervention patients reported that they were satisfied with point-of-care testing. In comparison with the control group, the intervention group had a higher level of agreement than control patients with statements relating to their satisfaction with the collection process (P<0.001) and confidence in the process (P<0.001). They also viewed point-of-care testing as strengthening their relationship with their GP (P = 0.010) and motivational in terms of better managing their condition (P<0.001).CONCLUSIONThe results from this trial support patient satisfaction and acceptability of point-of-care testing in a general practice setting.

BACKGROUNDPoint-of-care testing (PoCT) is increasingly being used in the general practice setting and has the potential to provide improved health outcomes for patients.OBJECTIVESThe aim of the study was to systematically assess the literature relating to the analytical performance, clinical effectiveness, cost and satisfaction of patients and health professionals with PoCT for monitoring patients with diabetes, with hyperlipidaemia or requiring anticoagulant therapy in general practice.METHODSSystematic review and synthesis of randomized and quasi-randomized trials during 1966-2007 was performed. PubMed, EMBASE, CINAHL, Current Contents, BIDS and the Cochrane Library databases were searched using key terms relating to PoCT for diabetes (glycosylated haemoglobin, urine albumin creatinine ratio), hyperlipidaemia (total cholesterol, triglycerides and high-density lipoprotein) and anticoagulant therapy (international normalized ratio) in the general practice setting.RESULTSNine papers from six randomized or quasi-randomized trials were included in the review. Large between-study heterogeneity made pooling of the data inappropriate. In terms of clinical effectiveness, no study found a significant difference between PoCT and pathology laboratory testing. There was a similar lack of data in relation to the analytical performance of PoCT, to cost outcomes and to patient and health professional satisfaction, making conclusions difficult to infer.CONCLUSIONSThis systematic review does not provide robust evidence that PoCT in general practice improves patient health outcomes, that it has comparable analytical quality to pathology laboratory testing, that it is cost-effective compared to usual care or that patients and health professionals find PoCT satisfactory. The number of trials is low, the follow-up of patients is short and many of the trials did not investigate PoCT as a separate intervention.

AIM:At a time when workforce shortages in general practices are leading to greater role substitution and skill-mix diversification, and the demand on general practices for chronic disease care is increasing, the structure and function of the general practice team is taking on heightened importance. To assist general practices and the organizations supporting them to assess the effectiveness of their chronic care teamworking, we developed an interview tool, the Chronic Care Team Profile (CCTP), to measure the structure and function of teams in general practice. This paper describes its properties and potential use.METHOD:An initial pool of items was derived from guidelines of best-practice for chronic disease care and performance standards for general practices. The items covered staffing, skill-mix, job descriptions and roles, training, protocols and procedures within the practice. The 41-item pool was factor analysed, retained items were measured for internal consistency and the reduced instrument's face, content and construct validity were evaluated.RESULTS:A three-factor solution corresponding to non-general practitioner staff roles in chronic care, administrative functions and management structures provided the best fit to the data and explained 45% of the variance in the CCTP. Further analyses suggested that the CCTP is reliable, valid and has some utility.DISCUSSION:The CCTP measures aspects of the structure and function of general practices which are independent of team processes. It is associated with the job satisfaction of general practice staff and the quality of care provided to patients with chronic illnesses. As such, the CCTP offers a simple and useful tool for general practices to assess their teamworking in chronic disease care.