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

Experience of care of hospitalized newborns and young children and their parents: A scoping review

INTRODUCTION

Several global initiatives put parent involvement at the forefront of enabling children's well-being and development and to promote quality of care for newborns and hospitalized young children aged 0-24 months. Scanty evidence on mistreatment such as delays or neglect and poor pain management among newborns exists, with even less exploring the experience of their parents and their hospitalized young children. To address this gap, authors reviewed research on experience of care for hospitalized young children and their parents, and potential interventions that may promote positive experience of care.

METHODS

A scoping review of English language articles, guidelines, and reports that addressed the experiences of care for newborns and sick young children 0-24 months in health facilities was conducted. Multiple databases: PubMed, PROSPERO, COCHRANE Library and Google Scholar were included and yielded 7,784 articles. Documents published between 2009 and November 2020, in English and with evidence on interventions that addressed family involvement and partnership in care for their sick children were included.

RESULTS

The scoping review includes 68 documents across 31 countries after exclusion. Mistreatment of newborns comprises physical abuse, verbal abuse, stigma and discrimination, failure to meet professional standards, poor rapport between providers and patients, poor legal accountability, and poor bereavement and posthumous care. No literature was identified describing mistreatment of hospitalized children aged 60 days- 24 months. Key drivers of mistreatment include under-resourced health systems and poor provider attitudes. Positive experience of care was reported in contexts of good parent-provider communication. Three possible interventions on positive experience of care for hospitalized young children (0-24 months) emerged: 1) nurturing care; 2) family centered care and 3) provider and parental engagement. Communication and counseling, effective provider-parental engagement, and supportive work environments were associated with reduced anxiety and stress for parents and hospitalized young children. Few interventions focused on addressing providers' underlying attitudes and biases that influence provider behaviors, and how they affect engaging with parents.

CONCLUSION

Limited evidence on manifestations of mistreatment, lack of respectful care, drivers of poor experience and interventions that may mitigate poor experience of care for hospitalized young children 0-24 months especially in low resource settings exists. Design and testing appropriate models that enhance socio-behavioral dimensions of care experience and promote provider-family engagement in hospitals are required.

Connecting Obstetric, Maternity, Pediatric and Preventive Child Health Care: A Comparative Prospective Study Protocol

Collaboration between birth care and Preventive Child Health Care (PCHC) in the Netherlands is so far insufficient. The aim of the Connecting Obstetric; Maternity; Pediatric and PCHC (COMPLETE) study is to: (1) better understand the collaboration between birth care and PCHC and its underlying mechanisms (including barriers and facilitators); (2) investigate whether a new multidisciplinary strategy that is developed as part of the project will result in improved collaboration. To realize the first aim, a mixed-method study composed of a (focus group) interview study, a multiple case study and a survey study will be conducted. To realize the second aim, the new strategy will be piloted in two regions in an iterative process to evaluate and refine it, following the Participatory Action Research (PAR) approach. A prospective study will be conducted to compare outcomes related to child health, patient reported outcomes and experiences and quality of care between three different cohorts (i.e., those that were recruited before, during and after the implementation of the strategy). With our study we wish to contribute to a better understanding of collaboration in care and develop knowledge on how the integration of birth care and PCHC is envisioned by stakeholders, as well as how it can be translated into practice.

Emergency Department Visits During the Postpartum Period: A Canadian Cohort Study

STUDY OBJECTIVE

Challenges in transitioning from obstetric to primary care in the postpartum period may increase emergency department (ED) visits. This study described the frequency, characteristics, and predictors of maternal ED visits in the postpartum period.

METHODS

Retrospective cohort study of all live-birth pregnancies occurring in Alberta (Canada) between 2011 and 2017. Individual-level health and ED utilization data was linked across 5 population health databases. We calculated age-standardized ED visit rates in the postpartum period and used negative binomial regression models to assess the outcome of any ED visit in the postpartum period associated with relevant sociodemographic and clinical factors. Results were reported using rate ratios (RRs) and 95% confidence intervals (95% CIs).

RESULTS

Data on 255,929 pregnancies from 193,965 individuals were analyzed. During the study period, 44.7% of pregnancies had 1 or more ED visits; 29.7% of visits occurred within 6 weeks after delivery. Increased postpartum ED visits were associated with living in remote (RR, 2.8; 95% CI, 2.6 to 2.9) or rural areas (RR, 2.3; 95% CI, 2.3 to 2.4), age less than 20 years (RR, 2.5; 95% CI, 2.4 to 2.6), mental (RR, 1.6; 95% CI, 1.6 to 1.7) and major/moderate health conditions (RR, 1.5; 95% CI, 1.5 to 1.6), multiparity 4 or more (RR, 2.0; 95% CI, 1.9 to 2.1), cesarean delivery (RR, 1.4; 95% CI, 1.4 to 1.4), and intensive prenatal care (RR, 1.4; 95% CI, 1.4 to 1.5).

CONCLUSION

Almost one third of ED visits in the postpartum occurred within 6 weeks immediately after delivery. Potential gaps in equitable access and quality of prenatal care should be bridged by appropriate transitions to primary care in the postpartum period.

The effects of continuity of care on the health of mother and child in the postnatal period: a systematic review

BACKGROUND

Continuity of care (COC) is essential for high-quality patient care in the perinatal period. Insights in the effects of COC models on patient outcomes are important to direct perinatal healthcare organization. To our knowledge, no previous review has listed the effects of COC on the physical and mental health of mother and child in the postnatal period.

METHODS

A search was conducted in four databases (PubMed, Web of Knowledge, CENTRAL and CINAHL), from 2000 to 2018. Studies were included if: participants were healthy mothers or newborns with a gestational age between 37-42 weeks; they covered the perinatal period and aimed to measure breastfeeding or any outcome related to the maternal/newborn physical or mental health. At least one of the three COC types (management, informational and relationship) was identified in the intervention. The methodological quality was assessed.

RESULTS

Ten articles were included. COC is mostly present in the identified care models. The effects of COC on the outcomes of mother and child in the postnatal period seem mostly to be positive, although not always significant. The relation between COC and the outcomes can be influenced by confounding factors, like the socio-economic status of the included population. Interventions with COC during pregnancy appear to be more effective for all the studied outcome factors.

CONCLUSION

COC as management, relational and informational continuity starting antenatal has the most impact on the postnatal outcomes of mother and child.

Women's experiences of their interactions with health care providers during the postnatal period in Australia: a qualitative systematic review protocol

OBJECTIVE

The objective of the review is to explore and evaluate women's experiences of interactions with health care providers during their postnatal period.

INTRODUCTION

The postnatal period is a transformative time for women. Women experience significant change and adaptation, which could impact upon parenting confidence, health, and psychological outcomes during this time. The interaction women have with their health care providers during the postnatal period plays an integral role in improving these health outcomes.

INCLUSION CRITERIA

This qualitative review will explore the experiences of primiparous and multiparous women during the postnatal period with a key focus on evaluating the interactions they have with health care providers. It will include all studies that utilize qualitative methods (such as interviews and focus groups). Articles that explore the postnatal care experiences of women who have endured a pregnancy loss, given birth to a baby with complex needs, or those that solely focus on describing the neonatal and intensive care experiences, will not be included.

METHODS

PubMed, CINAHL, Embase, Emcare, and PsycINFO will be searched. Studies published from 2000 onwards and written in English will be assessed for inclusion. Studies that are selected initially will be assessed for methodological quality by two independent reviewers utilizing the JBI critical appraisal instrument for qualitative research.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020186384.

The role of registered nurses in primary care and public health collaboration: A scoping review

Aim

The purpose of this work was to examine the roles of Registered Nurses (RNs) in primary care (PC) and public health (PH) collaboration. Additionally, we aimed to explore whether the current scope of practice for RNs is adequate to support their roles in PC/PH collaboration.

Design

A scoping review of current literature relating to the RN's role in PC/PH collaboration was conducted using the PRISMA 2009 checklist.

Methods

The review used key terms: primary care, public health, collaboration, nursing and nurse role across six electronic databases; 23 articles that were included in the final review were published over a 7-year span.

Results

Four key RN roles relating to PC/PH collaboration were identified: relationship builder, outreach professional, programme facilitator and care coordinator. RNs supported transitions in chronic disease, communicable disease care and maternity care at various healthcare system levels including systemic, organizational, intrapersonal and interpersonal levels.

Medical and socio-demographic characteristics associated with patient-perceived continuity of primary care: A cross-sectional survey in Hangzhou, China

BACKGROUND

This study measured the perceived continuity of general practitioner (GP) care from the patient's perspective and identified the associated factors.

METHODS

A cross-sectional survey was carried out on 624 patients in community health care centres in Hangzhou, China. A self-designed Likert scale was used to measure patients' perceptions on informational, managerial, and relational continuity of GP care. An average score for three types of continuity ranging from 0 to 100 was calculated. Linear regression models were developed to determine the factors influencing continuity.

RESULTS

Average rating scores of 57.73 (±15.31), 50.74 (±17.18), 61.61 (±18.07), and 63.57 (±17.40) were found for total, informational, managerial, and relational continuity of care, respectively. Older patients reported a more positive rating on all types of continuity. Income was negatively associated with managerial continuity. The factors affecting informational, relational, and total continuities included chronic diseases, walking distance to nearest community health centres, signing a contract with a GP, and knowing the names of contracted GPs.

CONCLUSION

Patients' perception of continuity of GP care remains at a low level, especially for informational continuity. The varied association between continuity of care and identified factors suggests that targeted actions should be considered for improving the quality of GP services.

Women's views on contact with a health visitor during pregnancy: an interview study

AIM

To explore recent mothers' views of the health visiting antenatal contact in England.

BACKGROUND

English health visitors are mandated to be in contact with all women in the third trimester of pregnancy. The aim of this antenatal contact is to assess the needs of the family before the birth and support preparation for parenthood. Recent data show that this contact is provided fragmentarily and not always face-to-face. More information on how women view this contact could inform service provision.

METHODS

Twenty-nine mothers with a baby less than 1 year old were recruited via social media and word of mouth. Having had antenatal contact with a health visitor was not a requirement to participate in the study. Women took part in face-to-face or phone interviews and all recordings were transcribed verbatim. Data were analysed using systematic thematic analysis.

FINDINGS

Eleven women had contact with a health visitor during pregnancy: nine through a home visit, one via a letter and one via a phone call. The remaining 18 women were asked about what they would have wanted from an antenatal contact. Three themes were identified: relationship building, information provision, and mode and time of contact. Some participants who had experienced a home visit reported building rapport with their health visitor before the postnatal period, but not everyone had this experience. Women reported requesting and receiving information about the health visiting service and the role of the health visitor. Finally, women suggested different modes of contact, suggesting a letter or that the information about health visiting could be provided by a midwife. A few women preferred a home visit. These study findings show women were unclear regarding the aim of the health visitor antenatal contact. As such, the contact is unlikely to reach its full potential in supporting parents-to-be.

Nurse liaison: a strategy for counter-referral

ABSTRACT Objective: to identify the profile of the counter-referred patients by the “nurse liaison” and to describe the experience of the professionals who participated in the project. Method: intervention research, with twelve nursing nurses from a hospital and an Emergency Care Unit, and 26 nurses from Primary Health Care. Data were obtained through questionnaires and counter-referral forms. Results: Out of 43 counter-referred individuals, 62.8% are over sixty years, 53.5% are men with multi-pathologies. Among the positive aspects, the nurses highlighted the dialogue between health care services, agility in the acquisition of inputs for the continuity of care in primary care, benefiting patients after hospital discharge. The greatest challenge was the lack of time and the deficit of nurses to perform the function. Final considerations: the presence of the “nurse liaison” has proved to be an important strategy to improve integration between services and to promote continuity of care.

Realist evaluation of an enhanced health visiting programme

Background

The health visitors’ role in many countries is changing. In Scotland, the role has undergone substantial changes through the introduction of an enhanced health visiting programme, which includes increased, structured home visits. This evaluation was conducted within NHS Ayrshire and Arran, one of the 14 Scottish Health Boards. Our aim was to understand and explain how, and why, the programme could contribute to improving health and wellbeing outcomes for children and families.

Methods

We used a realist evaluation approach, conducted in three phases. In phase one, eight managerial staff involved in developing and implementing the programme provided data, which were used to develop initial programme theories. In phase two, the programme theories were tested using qualitative data from 25 health visitors and 22 parents. The programme theories were refined through analyses and interpretation of data in phase three.

Results

The home visiting context provided by the programme interacted with the mechanisms of the programme and produced outcomes such as early identification of health and wellbeing issues amongst families who needed more support, leading to referral and engagement with sources of additional help. The home visits facilitated development of parent-health visitor relationships, and parents considered health visitors as their first point of contact on children’s wellbeing and developmental-related issues. Moreover, the programme provided more clarity to health visitors’ role, which in turn enhanced partnership working. However, there were aspects of the programme that may require further development. For instance, both parents and health visitors were concerned about the wide gaps between some home visits.

Conclusions

The enhanced health visiting programme increased opportunities for monitoring and early identification of health and wellbeing concerns. It created structures for a more efficient partnership working and ensured that the needs of children and families were supported. These benefits need to be evaluated further in an effectiveness study.

Does Coordinated Postpartum Care Influence Costs?

QUESTIONS UNDER STUDY

To investigate changes to health insurance costs for post-discharge postpartum care after the introduction of a midwife-led coordinated care model.

METHODS

The study included mothers and their newborns insured by the Helsana health insurance group in Switzerland and who delivered between January 2012 and May 2013 in the canton of Basel Stadt (BS) (intervention canton). We compared monthly post-discharge costs before the launch of a coordinated postpartum care model (control phase, n = 144) to those after its introduction (intervention phase, n = 92). Costs in the intervention canton were also compared to those in five control cantons without a coordinated postpartum care model (cross-sectional control group: n = 7, 767).

RESULTS

The average monthly post-discharge costs for mothers remained unchanged in the seven months following the introduction of a coordinated postpartum care model, despite a higher use of midwife services (increasing from 72% to 80%). Likewise, monthly costs did not differ between the intervention canton and five control cantons. In multivariate analyses, the ambulatory costs for mothers were not associated with the post-intervention phase. Cross-sectionally, however, they were positively associated with midwifery use. For children, costs in the post-intervention phase were lower in the first month after hospital discharge compared to the pre-intervention phase (difference of -114 CHF [95%CI -202 CHF to -27 CHF]), yet no differences were seen in the cross-sectional comparison.

CONCLUSIONS

The introduction of a coordinated postpartum care model was associated with decreased costs for neonates in the first month after hospital discharge. Despite increased midwifery use, costs for mothers remained unchanged.

Explaining culturally and linguistically diverse (CALD) parents' access of healthcare services for developmental surveillance and anticipatory guidance: qualitative findings from the 'Watch Me Grow' study

Background

Regular health visits for parents with young children provide an opportunity for developmental surveillance and anticipatory guidance regarding common childhood problems and help to achieve optimal developmental progress prior to school entry. However, there are few published reports from Australian culturally and linguistically diverse (CALD) communities exploring parents’ experiences for accessing child health surveillance programs. This paper aims to describe and explain parental experiences for accessing developmental surveillance and anticipatory guidance for children.

Methods

Qualitative data was obtained from 6 focus groups (33 parents) and seven in-depth interviews of CALD parents recruited from an area of relative disadvantage in Sydney. Thematic analysis of data was conducted using an ecological framework.

Results

An overarching theme of “awareness-beliefs-choices” was found to explain parents’ experiences of accessing primary health care services for children. “Awareness” situated within the meso-and macro-systems explained parents knowledge of where and what primary health services were available to access for their children. Opportunities for families to obtain this information existed at the time of birth in Australian hospitals, but for newly arrived immigrants with young children, community linkages with family and friends, and general practitioner (GPs) were most important. “Beliefs” situated within the microsystems included parents’ understanding of their children’s development, in particular what they considered to be “normal” or “abnormal”. Parental “choices”, situated within meso-systems and chronosystems, related to their choices of service providers, which were based on the proximity, continuity, purpose of visit, language spoken by the provider and past experience of a service.

Conclusions

CALD parents have diverse experiences with primary health care providers which are influenced by their awareness of available services in the context of their duration of stay in Australia. The role of the general practitioner, with language concordance, suggests the importance of diversity within the primary care health workforce in this region. There is a need for ongoing cultural competence training of health professionals and provisions need to be made to support frequent use of interpreters at general practices in Australia.

‘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.

Interprofessional cooperation by midwives in the field of out-of-hospital obstetrical care: an integrative review / Interprofessionelle Kooperation von Hebammen im Handlungsfeld der ambulanten geburtshilflichen Versorgung: ein integratives Review

The central objective of early prevention in Germany is an improved cooperation between professional groups of the health services and child and youth welfare in interprofessional networks. This objective derives from the realisation that proper care for families with infants can only be achieved if the various groups act in close integration. The ‘Federal Initiative early prevention’ explicitly calls for freelance midwives to be integrated in this context. However, only a few scientific findings on midwives’ cooperation in networks of early prevention have been published to date. This integrative review aims to identify the central themes of interprofessional cooperation of midwives in out-of-hospital obstetrical care from national and international research literature.

A systematic search of five research databases for publications between 2005 and 2015 was performed, complemented by a manual search.

25 studies were identified describing various contexts where midwives in out-of-hospital obstetrical care cooperate with other professional groups. Four key themes were analysed: contexts of cooperation, benefits of cooperation, facilitating and restrictive factors of cooperation, and competencies of cooperation. The studies show that there is only limited research coverage of the midwives’ perspective regarding interprofessional cooperation. The existing studies examine the cooperation of midwives primarily with health care professionals, and secondarily with professionals in the social services.

In order to expand knowledge on the cooperation of freelance midwives in the networks of early prevention, future research should focus on the perspective of midwives regarding cooperation with other professional groups, both in the health care sector and in the field of social services.

Responding to families with complex needs: a national survey of child and family health nurses

AIMS

The aim of this study was to explore the extent to which Australian child and family health nurses work with families with complex needs and how their practice responds to the needs of these families.

BACKGROUND

Many families with young children face challenges to their parenting capacity, potentially placing their children at risk of poorer developmental outcomes. Nurses increasingly work with families with mental health problems, trauma histories and/or substance dependence. Universal child health services must respond effectively to these challenges, to address health inequalities and to promote the best outcomes for all children and families.

DESIGN

The descriptive study used cross-sectional data from the first national survey of child and family health nurses in Australia, conducted during 2011.

METHODS

Survey data reported how often, where and how child and family health nurses worked with families with complex needs and their confidence in nursing tasks.

FINDINGS

Many, but not all, of the 679 respondents saw families with complex needs in their regular weekly caseload. Child and family health nurses with diverse and complex caseloads reported using varied approaches to support their clients. They often undertook additional professional development and leadership roles compared with nurses who reported less complex caseloads. Most respondents reported high levels of professional confidence.

CONCLUSION

For health services providing universal support and early intervention for families at risk, the findings underscore the importance of appropriate education, training and support for child and family health professionals. The findings can inform the organization and delivery of services for families in Australia and internationally.

Safe start at home: what parents of newborns need after early discharge from hospital - a focus group study

Background

The length of postpartum hospital stay is decreasing internationally. Earlier hospital discharge of mothers and newborns decreases postnatal care or transfers it to the outpatient setting. This study aimed to investigate the experiences of new parents and examine their views on care following early hospital discharge.

Methods

Six focus group discussions with new parents (n = 24) were conducted. A stratified sampling scheme of German and Turkish-speaking groups was employed. A ‘playful design’ method was used to facilitate participants communication wherein they used blocks and figurines to visualize their perspectives on care models The visualized constructions of care models were photographed and discussions were audio-recorded and transcribed verbatim. Text and visual data was thematically analyzed by a multi-professional group and findings were validated by the focus group participants.

Results

Following discharge, mothers reported feeling physically strained during recuperating from birth and initiating breastfeeding. The combined requirements of infant and self-care needs resulted in a significant need for practical and medical support.

Families reported challenges in accessing postnatal care services and lacking inter-professional coordination. The visualized models of ideal care comprised access to a package of postnatal care including monitoring, treating and caring for the health of the mother and newborn. This included home visits from qualified midwives, access to a 24-h helpline, and domestic support for household tasks. Participants suggested that improving inter-professional networks, implementing supervisors or a centralized coordinating center could help to remedy the current fragmented care.

Conclusions

After hospital discharge, new parents need practical support, monitoring and care. Such support is important for the health and wellbeing of the mother and child. Integrated care services including professional home visits and a 24-hour help line may help meet the needs of new families.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1300-2) contains supplementary material, which is available to authorized users.

Continuity of care in the post partum period: general practitioner experiences with communication

Objectives Informational and management continuity of care assists in providing a seamless transition for women and infants from tertiary or secondary to primary care during the post partum period. Few studies have evaluated the interaction between different aspects of the health system following a woman’s discharge from hospital after the birth of her infant. The present study describes how general practitioners (GPs) experience communications with hospitals and other post partum care providers relevant to continuity of care. Methods In the present cross-sectional study, a 52-item questionnaire adapted from a previously used survey was mailed to 932 GPs in southern Queensland, Australia, between February and July 2013. Questionnaire items included participant demographics, the timeliness and usability of discharge summaries, communication with other post partum care providers and consultation practices. Results The response rate was 17.4%. Nearly one-quarter of participants never or rarely received a hospital discharge summary in a timely manner and most considered the summaries somewhat useful. Few GPs (14.3%) had contact with or received information from domiciliary midwives who conducted post partum home visits. A higher proportion (38%) had some communication with a Child and Family Health nurse in the month before the survey. Conclusions Information flow from hospital to general practice and between other post partum care providers is less than ideal and may affect ongoing care for mothers and infants, especially those at risk. Knowledge exchange between healthcare services and initiatives to improve information sharing needs to be developed and implemented. What is already known on this topic? Transitions from tertiary or secondary care to primary care and between primary care providers are often times of vulnerability for patients, including women and infants in the post partum period. There is little information documenting communications between different maternity services and GPs that facilitate ongoing care. What does this paper add? There are significant gaps in the exchange of information about post partum women and infants from hospitals to GPs and a lack of communication between GPs and other post partum care providers, such as domiciliary midwives and Child and Family Health nurses. What are the implications for practitioners? Improvements in the timeliness, presentation and content of hospital discharge summaries, as well as enhancing channels of communication, collaboration, cooperation and information sharing between providers of community post partum care, are necessary if mothers are to receive the best care possible.

Beyond birth: Women's concerns about post-birth care in an Australian urban community

BACKGROUND

The provision of post-birth care in the community is changing substantially in many parts of Australia including Queensland, where there has been a burgeoning of clinics in private retail outlets such as pharmacies. Little is known about women's experiences of post-birth care in community pharmacies, nor of how their experiences compare with those in publicly-funded Child and Family Health Clinics (CFHC).

AIM

To provide qualitative insights into women's experiences of the different forms of post-birth care in the community, and identify where improvements could be made to service provision.

METHODS

A purposive sample of mothers of infants aged under 12 months was recruited to maximise variation in the use of private and public postnatal care services. Semi structured interviews were conducted with fifteen mothers whose antenatal, birthing and post-birth experiences varied across public and private sectors and birthing providers.

RESULTS

Concerns about lack of information and psychosocial support following discharge from hospital were widely reported, particularly by women who had given birth in a private facility under the care of a private obstetrician. Women used both pharmacy nurses and CFHCs. Pharmacy nurses were generally preferred for their accessibility, psychosocial support for mother, and continuity of care. However, these services are unregulated and without quality assurance mechanisms. Mothers found CFHCs regimented, focused on infant surveillance rather than support for mothers, and difficult to access.

CONCLUSION

There is a clear need for community post-birth care that will provide mothers with the information and psychosocial support they need. Currently, private, home-birth midwives and pharmacy nurses are providing women-centred care more effectively than nurses in publicly funded CFHC or GPs. This seems to be linked to continuity of carer, and to service priorities, resulting in inequities and systematic variations in the quality of post-birth care. Further research on this important health care issue is recommended.