Women's views of their postnatal care by midwives at an Adelaide Women's Hospital

A statewide review of postnatal care in private hospitals in Victoria, Australia

BACKGROUND

Concerns have been raised in Australia and internationally regarding the quality and effectiveness of hospital postnatal care, although Australian women receiving postnatal care in the private maternity sector rate their satisfaction with care more highly than women receiving public maternity care. In Victoria, Australia, two-thirds of women receive their maternity care in the public sector and the remainder in private health care sector. A statewide review of public hospital postnatal care in Victoria from the perspective of care providers found many barriers to care provision including the busyness of postnatal wards, inadequate staffing and priority being given to other episodes of care; however the study did not include private hospitals. The aim of this study was replicate the review in the private sector, to explore the structure and organisation of postnatal care in private hospitals and identify those aspects of care potentially impacting on women's experiences and maternal and infant care. This provides a more complete overview of the organisational structures and processes in postnatal care in all Victorian hospitals from the perspective of care providers.

METHODS

A mixed method design was used. A structured postal survey was sent to all Victorian private hospitals (n = 19) and key informant interviews were undertaken with selected clinical midwives, maternity unit managers and obstetricians (n = 11). Survey data were analysed using descriptive statistics and interview data analysed thematically.

RESULTS

Private hospital care providers report that postnatal care is provided in very busy environments, and that meeting the aims of postnatal care (breastfeeding support, education of parents and facilitating rest and recovery for women following birth) was difficult in the context of increased acuity of postnatal care; prioritising of other areas over postnatal care; high midwife-to-woman ratios; and the number and frequency of visitors. These findings were similar to the public review. Organisational differences in postnatal care were found between the two sectors: private hospitals are more likely to have a separate postnatal care unit with single rooms and can accommodate partners' over-night; very few have a policy of infant rooming-in; and most have well-baby nurseries. Private hospitals are also more likely to employ staff other than midwives, have fewer core postnatal staff and have a greater dependence on casual and bank staff to provide postnatal care.

CONCLUSIONS

There are similarities and differences in the organisation and provision of private postnatal care compared to postnatal care in public hospitals. Key differences between the two sectors relate to the organisational and aesthetic aspects of service provision rather than the delivery of postnatal care. The key messages emerging from both reviews is the need to review and monitor the adequacy of staffing levels and to develop alternative approaches to postnatal care to improve this episode of care for women and care providers alike. We also recommend further research to provide a greater evidence-base for postnatal care provision.

Women's experiences of infant feeding support in the first 6 weeks post-birth

Research suggests women find the first 2 to 6 weeks to be the most difficult time for breastfeeding. It has been identified that women need and seek support with breastfeeding during this time. Support is a difficult concept to define. When discussed by professionals, support for breastfeeding is generally viewed in terms of providing information and educational interventions. There is little understanding of the different elements of breastfeeding support strategies and the mechanisms by which support operates. Further, there is a paucity of qualitative research specifically reporting women's experiences and expectations of professional support. This paper describes women's expectations and experiences of 'infant feeding support' provided by health professionals in the first 6 weeks post-birth. The findings are drawn from a grounded theory study exploring women's infant feeding decisions in the first 6 weeks post-birth. Participants were recruited from a variety of socio-demographic areas of Sydney and the NSW Central Coast, Australia in 2003-2004. The women in this study discussed aspects of what they considered helpful and/or unhelpful in terms of professional support. In addition, they also provided insight into aspects of interactions that were deemed important to them as new mothers learning to feed their babies. The results are presented in three sections: expecting support, experiencing support and evaluating support. The findings help to better understand components of professional practices and behaviours that can be considered supportive. The support behaviours are far more complex than simply increasing education and knowledge of infant feeding. They demonstrate the need for sensitive individualized care and show that this type of support can increase women's confidence to breastfeed.

Is the organisation and structure of hospital postnatal care a barrier to quality care? Findings from a state-wide review in Victoria, Australia

OBJECTIVE

to describe the structure and organisation of hospital postnatal care in Victoria, Australia.

DESIGN

postal survey sent to all public hospitals in Victoria (n=71) and key-informant interviews with midwives and medical practitioners (n=38).

SETTING

Victoria, Australia.

PARTICIPANTS

providers of postnatal care in Victorian public hospitals.

FINDINGS

there is significant diversity across Victoria in the way postnatal units are structured and organised and in the way care is provided. There are differences in numerous practices, including maternal and neonatal observations and the length of time women spend in hospital after giving birth. Although the benefits of continuity of care are recognised by health care providers, continuity is difficult to provide in the postnatal period. Postnatal care is provided in busy, sometimes chaotic environments, with many barriers to providing effective care and few opportunities for women to rest and recover after childbirth. The findings in this study can, in part, be explained by the lack of evidence that has been available to guide early postnatal care.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

current structures such as standard postnatal documentation (clinical pathways) and fixed length of stay, may inhibit rather than support individualised care for women after childbirth. There is a need to move towards greater flexibility in providing of early postnatal care, including alternative models of service delivery; choice and flexibility in the length of stay after birth; a focus on the individual with far less emphasis on care being structured around organisational requirements; and building an evidence base to guide care.

Breastfeeding practice in the UK: midwives' perspectives

Despite breastfeeding prevalence increasing, many mothers in developed countries are dissatisfied with care provided by midwives. However, a paucity of research exists related to midwives' experiences of supporting breastfeeding mothers. This study explored the experiences of English midwives' during their breastfeeding support role. A qualitative study using grounded theory principles was used. Data were collected using in-depth interviews and analysed using constant comparative techniques. The setting was two maternity hospitals in the North of England, UK. Thirty midwives who cared for normal, healthy babies participated. Volunteers were recruited using theoretical sampling techniques. The core category that emerged is called 'surviving baby feeding' and relates to midwives' experiences when supporting mothers. The results reported in this paper refer to one category called 'doing well with feeding' which has three main themes: (1) communicating sensitively, (2) facilitating breastfeeding, and (3) reducing conflicting advice. Participating midwives reported practice that suggests that they valued breastfeeding, attempted to provide realistic information and advice, and tried to minimise confusion for mothers. However, some midwives used an authoritative manner when conversing with mothers. English midwives' reported practice demonstrates that these midwives appreciated that breastfeeding mothers required specific support. However, breastfeeding education that encourages midwives to develop effective skills in ascertaining mother's needs, but also encourages mothers to effectively participate in their care, should be provided. Further research is needed to clarify breastfeeding mothers' expectations and needs.

How is maternal psychosocial health assessed and promoted in the early postnatal period? Findings from a review of hospital postnatal care in Victoria, Australia

OBJECTIVE

to describe how women's maternal health, particularly at a psychosocial level, is assessed and promoted during the postnatal hospital stay.

DESIGN

postal survey of public hospitals providing postnatal care and interviews with care providers.

SETTING

all publicly funded maternity units and selected health professionals in Victoria, Australia.

PARTICIPANTS

hospital postal survey: sixty six hospital respondents; interviews: 38 maternity unit managers, clinical midwives and medical practitioners.

FINDINGS

there was little consistency across the State in relation to routine observations of the mother. Physical checks were much more common than enquiring about how women felt physically. Practice in psychosocial assessment was also diverse, with care plans/maps (clinical pathways) being the main tool to guide assessment. Most participants reported that psychosocial assessment was undertaken during pregnancy. Follow-up after birth also varied. Hospital respondents reported that emotional well-being is assessed postnatally by observation and conversation with women. Participants who were interviewed reported that midwives had mixed skills in assessing and dealing with complex psychosocial issues. Three hospitals administer the Edinburgh Postnatal Depression Scale to women in the days after birth, and three hospitals provide routine sessions of structured debriefing. Survey participants reported that the busy and, at times, chaotic nature of postnatal wards affected the provision of care and the level of psychosocial support offered to women.

KEY CONCLUSIONS

although one of the stated aims of early postnatal care is the promotion of maternal well-being, the diversity of practices and the routine nature of many of these practices suggest that care is often not individualised or woman-centred. The reliance of detecting and managing women with particular psychosocial issues during pregnancy results in this aspect of care being given less priority postnatally than may be ideal.

IMPLICATIONS FOR PRACTICE

strategies are required to provide health professionals with guidelines and skills to enhance the detection of women who have, or have the potential to develop, health problems after birth. This requires a reorganisation of the way early postnatal care is provided in relation to the use of routine practices; the ability of caregivers to spend time with women in an environment that offers privacy and confidentiality; the structuring of care around individual needs; and opportunities for women to be cared for by caregiver/s with whom they have met before.

New parents' experiences of postnatal care in Sweden

PURPOSE

The aim was to study new parents' satisfaction with postnatal care and to estimate the proportion of fathers who were given the option of spending the night at the postnatal ward.

PROCEDURES

A questionnaire was mailed to new parents 6 months after the birth of their child in a Swedish hospital. The main outcome was overall satisfaction with postnatal care.

FINDINGS

Two hundred and ninety-four new mothers and 280 new fathers completed the questionnaire. Thirty-four percent of the mothers were dissatisfied with the overall postnatal care. The strongest associated factors for new mothers' dissatisfaction were: unfriendly and unhelpful staff (RR 10.3; 3.2-32), lack of support from staff (RR 6.4; 2.3-17.5), new fathers not permitted to stay overnight (RR 5.2; 1.8-14.5), dissatisfaction with postnatal checks of the woman herself (RR 2.6; 1.1-6.3) and dissatisfaction with practical breast-feeding support (RR 1.6; 1.2-2.1). Sixty-three percent of the fathers were given the option of spending the night at the postnatal ward. The fathers who chose not to spend the night on the ward were older, had other children and were dissatisfied that they were not allowed to play a greater role in the care of their newborn baby.

MAIN CONCLUSIONS

In order to increase patient satisfaction, the needs of the new family must be highlighted and more support and help provided to new parents on the postnatal ward. It is essential to have family oriented postnatal care and to give fathers the opportunity to stay overnight and involve them in the care of their newborn baby.

A state-wide review of hospital postnatal care in Victoria, Australia: the views and experiences of midwives

OBJECTIVE

to describe midwives' views and experiences of the provision and organisation of hospital-based postnatal care.

DESIGN

semi-structured interviews with key informants who provide hospital-based postnatal care.

SETTING

public hospitals in Victoria, Australia.

PARTICIPANTS

clinical midwives and midwifery managers (n=33).

FINDINGS

midwives remain positive about working in hospital-based postnatal care; however, their satisfaction is influenced by barriers to effective care beyond their control, which specifically limit the time available to spend with women. They described many constraints on their practice, including the length of hospital stay, inadequate midwife-to-woman ratios, the busyness of postnatal units, and the effect of visitors. Midwives viewed the aims of postnatal care to include education and support of women with breastfeeding and parenting skills, and helping in women's physical recovery after pregnancy and birth. Midwives' perceptions of the factors that influence women's satisfaction with postnatal care are consistent with what we know are women's views: continuity of care, individualised unrushed care, and flexibility in routine practices.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

midwives' views and experiences of hospital-based postnatal care are in accordance with women's views and experiences. They are less than satisfied with hospital-based postnatal care, and they perceive a need for individualised, unrushed, flexible care. With evidence from both providers and women about the unsatisfactory nature of the current provision and organisation of hospital-based postnatal care, new approaches to this episode of care need to be explored.

Staffing in postnatal units: is it adequate for the provision of quality care? Staff perspectives from a state-wide review of postnatal care in Victoria, Australia

Background

State-wide surveys of recent mothers conducted over the past decade in Victoria, one state of Australia, have identified that women are consistently less satisfied with the care they received in hospital following birth compared with other aspects of maternity care. Little is known of caregivers' perspectives on the provision ofhospital postnatal care: how care is organised and provided in different hospitals; what constrains the provision of postnatal care (apart from funding) and what initiatives are being undertaken to improve service delivery. A state-widereview of organisational structures and processes in relation to the provision of hospital postnatal care in Victoria was undertaken. This paper focuses on the impact of staffing issues on the provision of quality postnatal care from the perspective of care providers.

Methods

A study of care providers from Victorian public hospitals that provide maternity services was undertaken. Datawere collected in two stages. Stage one: a structured questionnaire was sent to all public hospitals in Victoria that provided postnatal care (n = 73), exploring the structure and organisation of care (e.g. staffing, routine observations, policy framework and discharge planning). Stage two: 14 maternity units were selected and invited to participate in a more in-depth exploration of postnatal care. Thirty-eight key informant interviews were undertaken with midwives (including unit managers, associate unit managers and clinical midwives) and a medical practitioner from eachselected hospital.

Results

Staffing was highlighted as a major factor impacting on the provision of quality postnatal care. There were significant issues associated with inadequate staff/patient ratios; staffing mix; patient mix; prioritisation of birth suites over postnatal units; and the use of non-permanent staff. Forty-three percent of hospitals reported having only midwives (i.e. no non-midwives) providing postnatal care. Staffing issues impact on hospitals' ability to provide continuity of care. Recruitment and retention of midwives are significant issues, particularly in rural areas.

Conclusion

Staffing in postnatal wards is a challenging issue, and varies with hospital locality and model of care. Staff/patient ratios and recruitment of midwives in rural areas are the two areas that appear to have the greatest negative impact on staffing adequacy and provision of quality care. Future research on postnatal care provision should include consideration of any impact on staff and staffing.

A critical ethnographic study of encounters between midwives and breast-feeding women in postnatal wards in England

OBJECTIVE

To explore the nature of interactions between midwives and breast-feeding women within postnatal wards.

DESIGN

A critical ethnographic study using participant observation and focused interviews.

SETTING

Two maternity units in Northern England, UK.

PARTICIPANTS

61 postnatal women and 39 midwives.

FINDINGS

The interactions between midwives and women were encompassed by the global theme of 'taking time and touching base'. However, most encounters were characterised by an absence of 'taking time' or 'touching base'. This related to midwives' experiences of temporal pressure and inability to establish relationality with women due to their working patterns. The global theme was underpinned by five organising themes: 'communicating temporal pressure'; 'routines and procedures'; 'disconnected encounters'; 'managing breast feeding'; and 'rationing information'.

KEY CONCLUSIONS

The organisational culture within the postnatal wards contributed to midwives experiencing profound temporal pressures and an inability to establish relationality with women. Within this context, the needs of breast-feeding women for emotional, esteem, informational and practical support were largely unmet.

IMPLICATIONS FOR PRACTICE

Transformative action is required to dramatically reorganise the provision of hospital-based, postnatal ward midwifery care in parts of the UK. This should include a re-conceptualisation of caring time, with recognition that midwives need sufficient time in order to give time to others. This, in turn, requires recognition that caring time is cyclical and rhythmical, allowing for relationality, sociability, mutuality and reciprocity. The midwifery staffing structure in postnatal wards needs to be reviewed, as it is unacceptable to midwives and service users for staff to be rapidly relocated according to other demands within the institution. Most radically, it is argued that now is the time to reconsider the suitability of the hospital as the place and space within which women commence their breast-feeding journey.

Immigrant women's views about care during labor and birth: an Australian study of Vietnamese, Turkish, and Filipino women

BACKGROUND

Few studies of immigrant women's views of maternity care in their new homelands have been conducted. In Victoria, Australia, approximately 1 woman in 7 giving birth was born overseas in a non-English speaking country. This paper examines the views of three groups of immigrant women about the care they received in hospital for the birth of their babies and compares the findings with a population-based statewide survey.

METHODS

Mothers in a New Country was a study of 318 Vietnamese, Turkish, and Filipino women interviewed about their maternity care experiences by bicultural interviewers 6 months after giving birth in Melbourne, Australia. The interview schedule was adapted from the 1994 Victorian Survey of Recent Mothers, a population-based postal survey of 1336 women.

RESULTS

Of the 3 groups, 27 percent of Vietnamese, 48 percent of Turkish, and 39 percent of Filipino women reported their care during labor and birth as "very good," figures significantly lower than for the statewide survey, in which 61 percent of women experiencing similar models of care described their care as "very good." This significant differential in views about care was also present for many individual aspects of care. In the current study of mothers in a new country, comments about aspects of care with which women were particularly happy and unhappy highlighted their appreciation of care that was safe, kind, supportive, and respectful, and conversely, illustrated how distressed women were when care failed to meet these basic standards.

CONCLUSIONS

What immigrant women wanted from their maternity care proved to be extremely similar to what Australian-born women--and women the world over--want. Unfortunately, immigrant women were much less likely to experience care that gave them what they wanted.

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.

How first-time mothers cope with child care while still in the maternity ward

The aim of the study was to ascertain those factors that are related to the way first-time mothers assess themselves to be coping with child care when leaving the maternity hospital. The study is part of a wider longitudinal project that follows-up first-time mothers' growth into motherhood for a period of 8 months after the birth. Data collection was done using a questionnaire distributed between January and May 1995. The sample comprised 271 first time mothers. The mothers completed the questionnaire on average on the fifth day after childbirth. A stepwise regression analysis was applied. The mothers who assessed themselves to be coping better with child care were those who went home feeling rested and in a good frame of mind and who had positive experience of child care in the maternity ward. The more functional support the mother perceived herself to receive from members of her social network the better she assessed herself to be coping with child care. Those mothers who had previous experience of taking care of infants also assessed themselves to be coping better with child care. On the basis of the research findings it may be stated that the first-time mother needs support from both nursing professionals and close relatives in order to trust their own abilities to cope better with child care during early motherhood.

The experiences of postpartum hospital stay and returning home among Thai mothers in Australia

OBJECTIVE

To describe the experience of postpartum care among Thai women in Melbourne, Australia.

DESIGN

Ethnographic interviews and participant observation with women in relation to postpartum care and practices.

SETTING

Melbourne Metropolitan Area, Victoria, Australia.

PARTICIPANTS

26 Thai born women who gave birth in Australia.

FINDINGS

The Thai women had varying views about the length of time they should spend in hospital and the care they received. Ten of the twelve women who had had a caesarean birth stayed in hospital for six or more days, consistent with the hospital practice. However, most of those who had had a vaginal delivery opted to go home earlier than the standard hospital practice of four days stay. This was because they were unhappy about specific hospital practices, the hospital environment, or because there are several Thai confinement customs, which, traditionally, a new mother must observe in order to maintain good health and avoid future ill health and which they were not able to follow in hospital. Nevertheless, most women were satisfied with their postpartum care. Most women were aware of the Thai cultural beliefs and practices. However, they showed varying ways of coping with the hospital environment in relation to their varying social situations.

IMPLICATIONS FOR PRACTICE

Thai women are diverse in their needs, perceptions and experience of postpartum care. Therefore, it is appropriate neither to stereotype all Thai women as requiring to follow traditional confinement practices nor to require them to adjust to standard hospital practices. Rather an environment of caring concern whereby each woman's individual needs can be solicited, understood and, where possible, attended to as required. The challenge is in achieving this.

Support, sensitivity, satisfaction: Filipino, Turkish and Vietnamese women's experiences of postnatal hospital stay

OBJECTIVE

To assess Filipino, Turkish and Vietnamese women's views about their care during the postnatal hospital stay.

DESIGN

Interviews were conducted with recent mothers in the language of the women's choice, 6-9 months after birth, by three bilingual interviewers.

PARTICIPANTS

Three hundred and eighteen women born in the Philippines (107), Turkey (107) and Vietnam (104) who had migrated to Australia.

SETTING

Women were recruited from the postnatal wards of three maternity teaching hospitals in Melbourne, Australia, and interviewed at home.

FINDINGS

Overall satisfaction with care was low, and one in three women left hospital feeling that they required more support and assistance with both baby care and their own personal needs. The method of baby feeding varied between the groups, with women giving some insight into the reason for their choice. A significant minority wanted more help with feeding, irrespective of the method. The need for rest was a recurrent theme, with women stating that staff's attitudes to individual preferences, coupled with lack of assistance, made this difficult. The majority of comments women made regarding their postnatal stay focused on the attitude and behaviour of staff and about routine aspects of care. Issues related to culture and cultural practices were not of primary concern to women.

CONCLUSION

Maternity services need to consider ways in which care can focus on the individual needs and preferences of women.

The experience of pregnancy, labour and birth of Thai women in Australia

OBJECTIVE

To identify the perceptions and experience of pregnancy care, labour and birth of Thai women in Melbourne, Australia.

DESIGN

An ethnographic interview and participant observation with women in relation to pregnancy, labour and birth.

SETTING

Melbourne Metropolitan Area, Victoria, Australia.

PARTICIPANTS

30 Thai women who are now living in Melbourne.

FINDINGS

Thai women saw antenatal care as an important aspect of their pregnancy and sought care as soon as they suspected they were pregnant. They were more concerned about the well-being of their babies than their own health, therefore they attended all antenatal appointments. In general, these women were satisfied with care during labour, but some also had negative experiences with their caregivers and hospital routine. When asked to compare maternity services between Thailand and Australia, most of the women believed that services in Australia were better. However, women who had had good experiences of childbirth in Thailand, tended to have negative feelings about the Australian experience. There was also evidence in this study that most of these Thai women did not receive adequate information about care.

IMPLICATIONS FOR PRACTICE

Women's perceptions and experiences of antenatal care, labour and birth deserve attention, if appropriate and sensitive care is to be provided to women in Australia and elsewhere. It is only when women's voices are heard in all aspects of health-care delivery that we may see better and appropriate health services for women in childbirth.