Being connected: Exploring the needs of mothers during the postnatal period in Queensland, Australia

This project explored the needs of mothers beyond the immediate postnatal period in Queensland, Australia, for the development of improved models of care. Data were collected through group and individual interviews. A qualitative methodology using thematic analysis captured the experience of 58 participants. Four key themes were generated: Caring for self, Being connected, Getting direction and Having options. Being connected with care providers and peers was highly valued by participants as was having a sense of direction. Having a relationship with a carer who knew them personally throughout pregnancy and postnatal care avoided retelling stories and facilitated information sharing. Relationship-based care enabled mothers to better meet their personal needs necessary to fulfil the parenting role. Yet, many points of disconnect were identified including inconsistencies in information and gaps in care. These findings demonstrate a range of unmet needs, situated within a lack of relational continuity. Maternity and child health professionals, service managers and policy makers must reorient systems by listening, acknowledging and keeping the voice of mothers at the centre of care.

A complex postnatal mental health intervention: Australian translational formative evaluation

Reducing the burden of postnatal maternal mental health problems is an international public health priority. We developed What Were We Thinking (WWWT), a psychoeducation programme for primary postnatal health care that addresses known but neglected risks. We then demonstrated evidence of its effects in a before-and-after controlled study in preventing maternal postnatal mental health problems among women without a psychiatric history participating in the intervention compared to usual care (AOR 0.43; 95% CI 0.21, 0.89) when conducted by specialist nurses. Testing its effectiveness when implemented in routine primary care requires changes at practitioner, organizational and health system levels. This paper describes a programme of translational formative evaluation to inform the protocol for a cluster RCT. Following the UK Medical Research Council (MRC) Guidance for evaluating complex interventions, we conducted a translational formative evaluation using mixed methods. Collection and analysis of postnatal health service documents, semi-structured interviews, group discussions and an online survey were used to investigate service provision, consumers' needs and expectations, clinicians' attitudes and clinical practice, and the implications for health service delivery. Participants were expectant parents, health care providers, health service managers and government policy makers. Results documented current clinical practice, staff training needs, necessary service modifications to standardize advice to parents and include fathers, key priorities and drivers of government health policy, and informed a model of costs and expected health and social outcomes. Implementation of WWWT into routine postnatal care requires adjustments to clinical practice. Staff training, modifications to service opening hours and economic implications for the health system also need to be considered. The MRC Guidance for developing and evaluating complex interventions is a useful framework for conceptualizing and reporting translational formative evaluation, which is an essential step in the evidence trajectory. The results of the evaluation will inform the protocol for a cluster RCT of WWWT and associated health economic evaluation.

‘Lost and confused’: parent representative groups’ perspectives on child and family health services in Australia

Consumer involvement in health care is widely accepted in policy and service delivery. Australia offers universal health services for families with children aged 0 to 5 years, provided by child and family health nurses and general practitioners. Services include, but are not limited to, monitoring and promoting child health and development, and supporting parents. This paper reports consumer representatives’ perspectives on Australian parents’ needs and experiences of child and family health services, identifying facilitators and barriers to service utilisation. Twenty-six representatives from consumer organisations explored families’ experiences through focus groups. Qualitative data were analysed thematically. Consumer representatives identified several key implications for families using primary health services: feeling ‘lost and confused’ on the parenting journey; seeking continuity and partnership; feeling judged; and deciding to discontinue services. Participants highlighted accessible, timely, non-judgmental and appropriate interactions with healthcare professionals as vital to positive consumer experiences and optimal health and developmental outcomes. Representatives indicated that families value the fundamentals of well-designed health services: trust, accessibility, continuity, knowledge and approachability. However, both consumers and service providers face barriers to effective ongoing engagement in universally provided services.

Prevention of postnatal mental health problems in women: knowledge exchange in primary care in Victoria, Australia

ISSUE ADDRESSED

What Were We Thinking (WWWT) is a psychoeducation group program for the primary prevention of postnatal mental health problems in women. It addresses two neglected risks for postnatal depression and anxiety: unsettled infant behaviour and adjustments in the partner relationship after the birth of a first baby. WWWT has evidence of efficacy when facilitated by specialist nurses. It is designed to be facilitated by trained nurses as part of standard postnatal primary care. The aim of this study is to assess nurses' understanding of their role in prevention of postnatal mental health problems, the requirements for and feasibility of implementing WWWT, and nurses' current practice and specific training needs.

METHODS

Maternal and Child Health (MCH) coordinators emailed nurses at all Victorian MCH centres an invitation to participate in a study about parent-infant mental health. Semi-structured interviews and group discussions were conducted. Responses were analysed thematically.

RESULTS

MCH nurses demonstrated a willingness to implement a structured mental health-promotion intervention into clinical practice. Successful implementation will require changes to enable routine attendance of fathers at group sessions and recommendations to parents about the use of infant behaviour management strategies.

CONCLUSIONS

This study contributes to comprehensive knowledge exchange about the implementation of a complex intervention in standard primary care. This knowledge is essential for generating practice-based evidence of the WWWT mental health-promotion program's effectiveness. SO WHAT?: The findings will inform a training program for WWWT nurse facilitators and the protocol for a cluster randomised control trial (RCT) to test the effectiveness of WWWT in standard postnatal care.

Mothers' perceptions of primary health-care providers: thematic analysis of responses to open-ended survey questions

General practitioners and maternal, child and family health nurses have a central role in postpartum primary health care for women and their infants. Positive client-provider relationships are particularly important for women experiencing mental health problems or unsettled infant behaviour. However, little is known about their experiences of postnatal primary health care. The study aimed to describe views of postnatal primary health care among women completing a residential early parenting programme and to identify potential strategies to enhance provider-patient interactions. Participants (n=138) were women admitted with their infants to a private or a public early parenting service in Melbourne, Australia. Women completed a detailed self-report survey, including open-ended questions about experiences of primary health-care services, and a structured psychiatric interview to diagnose anxiety and depression. Survey responses were analysed thematically. Womens' experiences of primary health care were influenced by their perceptions of provider competence and the quality of interactions. While similar positive characteristics of doctor and nurse care were valued, medical and nursing practices were judged in different ways. Women described GPs who listened, understood and were thorough as providing good care, and maternal, child and family health nurses were valued for providing support, advice and encouragement. Threats to therapeutic relationships with doctors included feeling rushed during consultations, believing that GPs were not mental health-care providers and the clinician not being 'good' with the infant; with nurses, problems included feeling judged or given advice that was inconsistent or lacked an evidence-base. Postpartum primary health care will be improved by unhurried consultations, empathic recognition, encouragement, evidence-informed guidance and absence of criticism.

Smoothing out the transition of care between maternity and child and family health services: perspectives of child and family health nurses and midwives'

BACKGROUND

In Australia, women who give birth are transitioned from maternity services to child and health services once their baby is born. This horizontal integration of services is known as Transition of Care (ToC). Little is known of the scope and processes of ToC for new mothers and the most effective way to provide continuity of services. The aim of this paper is to explore and describe the ToC between maternity services to CFH services from the perspective of Australian midwives and child and family health (CFH) nurses.

METHOD

This paper reports findings from phase two of a three phase mixed methods study investigating the feasibility of implementing a national approach to CFH services in Australia (the CHoRUS study). Data were collected through a national survey of midwives (n = 655) and CFH nurses (n = 1098). Issues specifically related to ToC between maternity services and CFH services were examined using descriptive statistics and content analysis of qualitative responses.

RESULTS

Respondents described the ToC between maternity services and CFH services as problematic. Key problems identified included communication between professionals and services and transfer of client information. Issues related to staff shortages, early maternity discharge, limited interface between private and public health systems and tension around role boundaries were also reported. Midwives and CFH nurses emphasised that these issues were more difficult for families with identified social and emotional health concerns. Strategies identified by respondents to improve ToC included improving electronic transfer of information, regular meetings between maternity and CFH services, and establishment of liaison roles.

CONCLUSION

Significant problems exist around the ToC for all families but particularly for families with identified risks. Improved ToC will require substantial changes in information transfer processes and in the professional relationships which currently exist between maternity and CFH services.

Discontinuities between maternity and child and family health services: health professional's perceptions

BACKGROUND

Continuity in the context of healthcare refers to the perception of the client that care has been connected and coherent over time. For over a decade professionals providing maternity and child and family health (CFH) services in Australia and internationally have emphasised the importance of continuity of care for women, families and children. However, continuity across maternity and CFH services remains elusive. Continuity is defined and implemented in different ways, resulting in fragmentation of care particularly at points of transition from one service or professional to another.This paper examines the concept of continuity across the maternity and CFH service continuum from the perspectives of midwifery, CFH nursing, general practitioner (GP) and practice nurse (PN) professional leaders.

METHODS

Data were collected as part of a three phase mixed methods study investigating the feasibility of implementing a national approach to CFH services in Australia (CHoRUS study). Representatives from the four participating professional groups were consulted via discussion groups, focus groups and e-conversations, which were recorded and transcribed. In total, 132 professionals participated, including 45 midwives, 60 CFH nurses, 15 general practitioners and 12 practice nurses. Transcripts were analysed using a thematic approach.

RESULTS

'Continuity' was used and applied differently within and across groups. Aspects of care most valued by professionals included continuity preferably characterised by the development of a relationship with the family (relational continuity) and good communication (informational continuity). When considering managerial continuity we found professionals' were most concerned with co-ordination of care within their own service, rather than focusing on the co-ordination between services.

CONCLUSION

These findings add new perspectives to understanding continuity within the maternity and CFH services continuum of care. All health professionals consulted were committed to a smooth journey for families along the continuum. Commitment to collaboration is required if service gaps are to be addressed particularly at the point of transition of care between services which was found to be particularly problematic.