Satisfaction with postnatal care--the choice of home or hospital

A randomised controlled trial of maternal satisfaction with the routine examination of the newborn baby at three months post birth

OBJECTIVE

to determine whether any differences in maternal satisfaction with the examination of a newborn baby between midwives and junior paediatricians are maintained over a three-month period.

DESIGN, SETTING AND PARTICIPANTS

randomised controlled trial. Eight hundred and twenty-six mother and baby pairs in a district general hospital in South East England were randomised to a junior paediatrician or a midwife for the routine examination. Four hundred and eighty-six mothers completed a maternal satisfaction questionnaire on day-one and again three-months later. Maternal satisfaction with the examination was analysed in relation to randomised group, process and background variables.

FINDINGS

high satisfaction with the examination was reported by most mothers (day-one: 82%; three-months: 79%). At day-one, mothers whose babies were examined by a midwife were more satisfied with the examination (crude odds ratio (OR) for the lowest tertile of satisfaction 0.49, 95% CI 0.32-0.73). However, after controlling for provision of health education during the examination (e.g. discussing feeding, sleeping and skin care) and continuity of care provided, maternal satisfaction was no longer related to status of examiner (adjusted OR 0.83, 95% CI 0.52-1.33). Three months later, there was no significant difference in maternal satisfaction with midwife and junior paediatrician examinations of the newborn baby (crude OR 0.89, 95% CI 0.58-1.37). Discussion of health-care issues by the examiner during the examination was significantly related to increased satisfaction even at three-months. Three month ratings of low satisfaction with the examination were most strongly predicted by current maternal depressive mood, even when other factors were adjusted for (adjusted OR 2.58, 95% CI 1.19-5.59).

KEY CONCLUSIONS

from the mother's perspective, the quality of midwife examination is at least as satisfactory as that of junior paediatricians and this perception is maintained over a three-month period. Satisfaction can be significantly enhanced if the examiner provides information on behavioural and health-care issues. The examination of the newborn baby provides an important window of opportunity for sharing information on newborn behaviour and care issues.

Comprehensive measurement of maternal satisfaction: the modified Mason Survey

A three-stage process was undertaken to identify and modify a tool that was capable of measuring the many aspects of maternal satisfaction relevant to Australian women. First, the scope of maternal satisfaction to be measured was defined by summarizing available literature and surveys purporting to measure maternal satisfaction (including surveys used in maternity services in New South Wales). The multidimensional nature of maternal satisfaction was confirmed, with 16 core aspects (common to the literature and local surveys) and nine additional unique aspects of maternal satisfaction being identified. Second, these core and additional aspects were used to examine the comprehensiveness of the Mason Survey, a survey recommended by the National Health and Medical Research Council of Australia for use in maternity services. Eighty-eight per cent of the core and additional aspects (22/25) were found to be present in the Mason Survey. Third, an expert panel further modified the Mason Survey by removing items not applicable to the Australian context. The modified Mason Survey is a comprehensive measure of maternal satisfaction suitable for Australian women and capable of providing valuable information on the quality of services and future planning for maternity services.

Routine examination of the newborn and maternal satisfaction: a randomised controlled trial

OBJECTIVE

To determine whether the routine examination of the newborn by a midwife compared with a junior paediatrician (SHO) affects maternal satisfaction with this examination.

METHODS

Randomised controlled trial: 826 mother and baby pairs in a district general hospital in south east England were randomised to a paediatric SHO or a midwife for the routine newborn examination. Maternal satisfaction with the examination was analysed in relation to intervention group, process, and background variables.

RESULTS

Some 81% of mothers reported that they were satisfied or very satisfied with the newborn examination. Mothers assigned to a midwife were more satisfied with the newborn examination (crude odds ratio (OR) 0.54 (95% confidence interval (CI) 0.39 to 0.75), p < 0.001). However, after provision of health education during the examination, continuity of care provided, and history of miscarriage had been controlled for, status of examiner was no longer related to maternal satisfaction (adjusted OR 0.82 (95% CI 0.57-1.20), NS). The discussion of healthcare issues by the examiner (adjusted OR 0.49 (95% CI 0.34 to 0.70), p < 0.001) and continuity of care (adjusted OR 0.43 (95% CI 0.23 to 0.81), p < 0.01) were both related to enhanced satisfaction, and history of miscarriage (adjusted OR 1.61 (1.08 to 2.40), p < 0.05) was associated with lower maternal satisfaction with the newborn examination. Midwives (61%) were more likely than SHOs (33%) to discuss healthcare issues, such as feeding, sleeping, and skin care.

CONCLUSIONS

Mothers were more likely to be satisfied with the newborn examination by a midwife than an SHO because midwives were more likely to discuss healthcare issues during the examination and were able to provide continuity of care. However, midwife examinations according to exclusion criteria agreed with trial midwives excluded half of all newborns, and criteria may have to be reconsidered for practice implementation.

Parents' experience of early discharge from hospital after birth in Sweden

OBJECTIVE

to investigate the factors that influence the experience of mothers and fathers when they have chosen to return home, earlier than is the normal routine, following the birth of their baby.

DESIGN

a qualitative study, using open interviews, was undertaken. The text of the transcripts was coded and categorised according to the grounded theory method using constant comparative analysis.

SETTING

interviews were carried out with 12 parents, six mothers and six fathers, individually in their own homes. They had all left a maternity/family ward at the Helsingborg Hospital in southern Sweden within 26 hours of birth whereas the normal discharge time is 72 hours.

MEASUREMENTS AND FINDINGS

'a sense of security' was the core category. Achieving a sense of security linked to informed choice for early discharge appeared to be dependent on the following categories: (l) the midwives' empowering behaviour; (2) affinity within the family; (3) the parents' right to autonomy/control; (4) physical well-being. There appears to be an inner connection between each of these categories.

KEY CONCLUSIONS

the midwife's empowering behaviour supports the parents' sense of security and encourages their informed choice of earlier discharge after birth. When the mothers' and babies return home it strengthens the affinity within the family and the father's sense of participation.

Very early discharge from hospital after normal deliveries

The aim of the present study was to investigate, in a descriptive study, how healthy women experienced early discharge from hospital, 6-12 hours, after normal deliveries. Expecting couples were prepared for early discharge during pregnancy. The women delivered at the University Hospital in Uppsala. All infants had two obligatory medical examinations, one before leaving the hospital and one for metabolic screening after four or five days. Both mothers and infants received postpartum care at home by midwives. One hundred and three women participated and answered a questionnaire four to five days after delivery. Twenty of the women were additionally interviewed by telephone four months after delivery. The average length of stay at the hospital after delivery was 8 hours. The families had, on average, 1.9 visits at home. All women considered that they had received sufficient care and advice from the midwives, although 40 percent felt uncertainty about something in the postpartum period. Questions frequently raised concerned breast-feeding. Two infants were readmitted to hospital due to mild neonatal hyperbilirubinemia. All but three women wanted to repeat very early discharge after a future uncomplicated delivery. Ninety-five percent of the women were still breast-feeding after four months. We conclude, that antenatal preparation and a well-organised, adequate postpartum home-care is of the greatest importance, to establish safe early discharge after uncomplicated deliveries. This concept of early discharge from hospital, with midwifery home care provided, is safe and appreciated by the new parents.

Team midwifery: the influence of the midwife-woman relationship on women's experiences and perceptions of maternity care

The need to provide woman-centred maternity services which take account of womens' views and specifically address their need for choice, control and continuity has been advocated and team midwifery has been suggested as one of the ways to achieve these objectives. This paper explores women's descriptions of their maternity care experiences in England, specifically focusing on: their experiences of communication; being informed and making choices; being involved in the process of care; and their own perceptions of care. It is suggested that the midwife-woman relationship is an important aspect of satisfaction which needs greater recognition. Analysis of the data highlighted the importance of the quality of women's relationships with caregivers. Findings revealed how positive relationships facilitated conditions which influenced satisfaction with care and suggest that, for the development of genuine woman-centred services where women exercise informed choice, and are involved in, and have some control over, the process of care, the nature and quality of the midwife-woman relationship must be accepted as an integral and crucial aspect of the service.

Childbirth and the illness focus

Childbirth is essentially women's business, a natural female act being performed since the beginning of mankind. However, as Western society has evolved, so too has the management of childbirth. It is the medical profession that has gained control of providing care for childbearing women, to the detriment of many women's experiences. The societal expectations on childbearing women, the iatrogenic effects of pregnancy being treated as an illness under the medical model, and the implications for the profession of midwifery will be discussed.

Early discharge and risk for postnatal depression

OBJECTIVE

To determine whether early discharge (< 72 hours) after childbirth increased the risk for women developing postnatal depression.

DESIGN

Prospective cohort design consisting of an initial interview, and six-weekly assessments for 24 weeks using a self-report questionnaire and the Edinburgh Postnatal Depression Scale (EPDS). Women discharged within 72 hours were compared with the remaining women.

SETTING

Tertiary referral hospital in western Sydney, New South Wales, 1993.

PARTICIPANTS

All 749 women delivering over a three-month period were recruited. Of the 522 participants, 425 women completed the study.

MAIN OUTCOME MEASURES

Women scoring > 13 on the EPDS on two or more occasions were considered potential "cases" of postnatal depression. The diagnosis was confirmed using the Structured Clinical Interview for DSM-III-R disorders (SCID).

RESULTS

Of the 153 women (36%) discharged early, 22 women (14.4%) developed postnatal depression over the study period compared with 20 of the 272 women (7.4%) who had standard length of stay. Women who were discharged within 72 hours had a significantly increased risk for developing postnatal depression (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.07-4.21). This risk persisted when other sociodemographic, obstetric and psychosocial risk factors were controlled for in a logistic regression analysis (OR, 3.06; 95% CI, 1.22-7.69).

CONCLUSION

Women planning early discharge after childbirth should be carefully assessed before discharge and follow-up should be rigorous. The potential to develop postnatal depression should be considered in all women choosing early discharge from hospital.

A cost analysis of early discharge and domiciliary visits versus standard hospital care for low-risk obstetric clients

This paper presents an economic analysis of three obstetric early discharge schemes operating in western Sydney. The primary objective was to examine the net economic value of health service resources released due to each early discharge scheme. Conventional postnatal obstetric care comprised an inpatient stay of four to five days. Early discharge provided an alternative location. Clients who chose to participate in the scheme were discharged two to three days earlier than usual and visited at home by a midwife for up to seven days. Other studies of early discharge schemes have shown that resulting maternal and infant morbidity were no higher than with conventional care. This study took the form of a cost analysis. The early discharge schemes at Blacktown and Westmead Hospitals used more resources than they released, whereas the scheme at Auburn Hospital released resources in excess of those it used. Sensitivity analysis showed that the results for Westmead and Auburn Hospitals were sensitive to changes in key assumptions used in the analysis. The number of domiciliary visits per client was an important determinant of the ability of schemes to release resources in excess of their costs. The existence of early discharge provides an extra choice to clients in the location of postnatal care. The question for decision makers is whether this choice is worth the extra cost of early discharge schemes.

The value of early discharge: dispelling some myths

Our objective in this paper is to assess the value of early discharge schemes following the economic evaluation of three such schemes in New South Wales, Australia. An early discharge programme for obstetric patients, a fractured hip management programme and a continuing community cancer care programme were evaluated. The results of the economic evaluation of these schemes are discussed in the light of four commonly held beliefs about the value of early discharge: that early discharge schemes succeed in reducing length of stay, that early discharge schemes save money, that the welfare of patients is not reduced by early discharge and that early discharge schemes are cost-effective. The caution expressed by previous authors about the perceived advantages of early discharge schemes is still warranted.