Better Births - But why not better postnatal care?

What are the experiences of women and midwives of non-severe perineal trauma assessment? A meta-synthesis

BACKGROUND

In the UK, most women giving birth vaginally experience perineal trauma, predominantly non-severe, yet there is no validated assessment tool to evaluate wound healing postnatally. Current NICE guidelines provide only generic advice on how to complete this assessment, exposing the potential for a variety of non-standardised practices. Criticism of UK postnatal care is widespread, and inadequate perineal trauma assessment might contribute to this.

QUESTION

What are the experiences of women and midwives of non-severe perineal trauma assessment?

METHODS

Systematic literature review with meta-synthesis using three online databases. Data was synthesised using constant comparative analysis.

DATABASES

CINAHL, PubMed, and Web of Science.

FINDINGS

Nine studies exploring the experiences of women (8/9) and midwives (1/9) on non-severe perineal trauma were included. Three themes emerged: 'How society and healthcare professionals are silencing women's experiences', 'The inadequate provision of perineal care', and 'A glimmer of hope, examples of positive experiences'.

DISCUSSION

Women report being underprepared about the extent of their perineal trauma, the potential impact on their lives and the services available if concerns. Some women are not offered perineal assessment and feel their concerns are trivialised by clinicians. These issues are not unique to the UK, as similar challenges exist globally. Improving postnatal care requires better communication, a therapeutic woman-midwife relationship, and societal change to reduce stigma around perineal trauma, which impacts women's psycho-physical health.

CONCLUSION

Improving postnatal perineal trauma care is crucial, with research needed on assessment practices and tools. Therapeutic relationships and women-centred clinical pathways can enhance experiences.

Client-centered flexible planning of home-based postpartum care: A randomized controlled trial on the quality of care

BACKGROUND

Standardization of health systems often hinders client-centered care. This study investigates whether allowing more flexibility in the planning range of the Dutch home-based postpartum care service improves its quality of care, as innovative approach to client-centered care.

METHODS

A randomized controlled trial was conducted (2017-2019), in which pregnant women who intended to breastfeed were assigned into two groups (1:1). The intervention group was allowed to receive care up to the 14th-day postpartum, instead of the first 8-10 consecutive days ("usual care"). Primary outcome measure was the proportion of newborns still receiving exclusively breastmilk on final caring day of the service. This so-called successful breastfeeding rate is currently used by the Dutch health sector to measure the quality of care. Secondary outcome measures were self-care experience, overall care experience, and exclusive breastfeeding duration rate.

RESULTS

Based on data from 1275 participants, there was no difference in exclusive breastfeeding on final caring day (86,7% intervention group vs. 88,9% control group, RR: 1.03, 95% CI: 0.98-1.07). Both groups showed similar self-care experiences. Women in the intervention group had slightly poorer overall care experience and lower exclusive breastfeeding duration rates.

CONCLUSIONS

This study found no effect on the quality of care when allowing more flexibility in the planning range of home-based postpartum care. Women can, therefore, be offered more flexibility to suit them. Given the confusion in interpreting the sector's current main quality indicator, we call for an inclusive dialogue on how to best measure the quality of home-based postpartum care.

Community postnatal care delivery in England since Covid-19: A qualitative study of midwifery leaders' perspectives and strategies

PROBLEM

COVID-19 impacted negatively on maternity care experiences of women and staff. Understanding the emergency response is key to inform future plans.

BACKGROUND

Before the COVID-19 pandemic, experts highlighted concerns about UK community postnatal care, and its impact on long-term health, wellbeing, and inequalities. These appear to have been exacerbated by the pandemic.

AIM

To explore community postnatal care provision during and since the pandemic across a large diverse UK region.

METHODS

A descriptive qualitative approach. Virtual semi-structured interviews conducted November 2022-February 2023. All regional midwifery community postnatal care leaders were invited to participate.

FINDINGS

11/13 midwifery leaders participated. Three main themes were identified: Changes to postnatal care (strategic response, care on the ground); Impact of postnatal care changes (staff and women's experiences); and Drivers of postnatal care changes (COVID-19, workforce issues).

DISCUSSION

Changes to postnatal care during the pandemic included introduction of virtual care, increased role of Maternity Support Workers, and moving away from home visits to clinic appointments. This has largely continued without evaluation. The number of care episodes provided for low and high-risk families appears to have changed little. Those requiring additional support but not deemed highest risk appear to have been most impacted. Staffing levels influenced amount and type of care provided. There was little inter-organisation collaboration in the postnatal pandemic response.

CONCLUSION

Changes to postnatal care provision introduced more efficient working practices. However, evaluation is needed to ensure ongoing safe, equitable and individualised care provision post pandemic within limited resources.

Exploring the relationship between women’s experience of postnatal care and reported staffing measures: An observational study

Background

Women have reported dissatisfaction with care received on postnatal wards and this area has been highlighted for improvement. Studies have shown an association between midwifery staffing levels and postnatal care experiences, but so far, the influence of registered and support staff deployed in postnatal wards has not been studied. This work is timely as the number of support workers has increased in the workforce and there has been little research on skill mix to date.

Methods

Cross sectional secondary analysis including 13,264 women from 123 postnatal wards within 93 hospital Trusts. Staffing was measured in each organisation as Full Time Equivalent staff employed per 100 births, and on postnatal wards, using Hours Per Patient Day. Women’s experiences were assessed using four items from the 2019 national maternity survey. Multilevel logistic regression models were used to examine relationships and adjust for maternal age, parity, ethnicity, type of birth, and medical staff.

Results

Trusts with higher levels of midwifery staffing had higher rates of women reporting positive experiences of postnatal care. However, looking at staffing on postnatal wards, there was no evidence of an association between registered nurses and midwives hours per patient day and patient experience. Wards with higher levels of support worker staffing were associated with higher rates of women reporting they had help when they needed it and were treated with kindness and understanding.

Conclusion

The relationship between reported registered staffing levels on postnatal wards and women’s experience is uncertain. Further work should be carried out to examine why relationships observed using whole Trust staffing were not replicated closer to the patient, with reported postnatal ward staffing. It is possible that recorded staffing levels on postnatal wards do not actually reflect staff deployment if midwives are floated to cover delivery units. This study highlights the potential contribution of support workers in providing quality care on postnatal wards.

Community midwives views of postnatal care in the UK; A descriptive qualitative study

OBJECTIVE

To explore views and experiences of community midwives delivering postnatal care.

DESIGN

A descriptive qualitative study design undertaking focus groups with community midwives and community midwifery team leaders.

SETTING

All focus groups were carried out in community midwifery care settings, across four hospitals in two NHS organisations, April to June 2018 in the West Midlands, UK.

PARTICIPANTS

47 midwives: 34 community midwives and 13 community midwifery team leaders took part in 7 focus groups.

FINDINGS

Inductive framework analysis of data led to the development of themes and sub-themes relating to factors influencing discharge from hospital, strategies to address increases in discharge and the broader challenges to providing care. Conditions on the postnatal ward and women's experiences of care in the hospital were factors influencing timing of discharge from hospital that resulted in community midwives managing women and babies with more complex needs. In order to manage increased workloads, there was growing but varied use of flexible approaches to providing care such as telephone consultations, postnatal clinics, and maternity support workers.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

In a context of short postnatal hospital stays, community midwives appear to be responding to women's needs and service pressures in the postnatal period. Wider implementation of specific strategies to organise and deliver support to women and babies may further improve care and outcomes.

The maternal health-related issues that matter most to women in Ireland as they transition to motherhood - A qualitative study

BACKGROUND

Many studies on women's maternity care experiences reveal recurring issues that are poor or less than optimal. Women's opinions on the maternal health-related issues that matter most to them are essential if care and services are to be improved.

AIMS

To identify the maternal health-related issues that matter most to women in Ireland, based on their own experiences of maternity care, services and motherhood.

METHODS

A qualitative exploratory study with 24 women. Following university ethical approval, audio-recorded one-to-one telephone interviews were conducted and thematically analysed.

FINDINGS

We identified two themes, each with four subthemes, connected to a central concept of the invisible woman. Pendulum of care, and subthemes Inconsistent services, All about the baby, Induced anxiety and Information seesaw, illustrated the extremes of care and services that women experienced. Magnitude of motherhood, and subthemes Weight of responsibility, Real-time reassurance, Change of identity and Growth into advocacy, depicted the intensity of their new role while transitioning to motherhood.

DISCUSSION

Findings articulate the issues that mattered most to women in Ireland as they transitioned to motherhood. Some women identified specific research topics/areas, but all of the issues identified can be translated into researchable topics that seek to improve local care and service provision.

CONCLUSION

Given the recurring nature of women's less than satisfactory experiences of aspects of maternity care in many countries, it is likely that conducting research on issues that matters most to women will have the greatest impact on their health, wellbeing and lives as they transition to motherhood.

Second Opinions: Negotiating Agency in Online Mothering Forums

Study background

Online forums and other virtual communities are an increasing source of postpartum support and information for first-time mothers. However, there is little evidence about how new mothers in Canada access and use online resources.

Purpose

The purpose of this study was to examine how first-time mothers accessed information and support both online and off-line during the first six months postpartum and how their experiences were constructed through social and institutional discourses.

Methods

A qualitative feminist poststructuralist approach was used to analyze an online discussion board with first-time mothers in Nova Scotia.

Results

Mothers who used the online discussion board experienced a sense of community with other mothers where empathy and encouragement were integral to the ways in which information and support were shared. “Weak ties” (with strangers) were important and led to the following themes: (a) empathy, encouragement, and information; (b) socialization; (c) blurring the boundaries of online and off-line networks; and (d) Developing community.

Conclusions

These online forums offer insight for health professionals looking to improve mothers’ care postpartum and point to a need to foster spaces for new mothers to talk to each other.