Individualised, flexible postnatal care: a feasibility study for a randomised controlled trial

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.

Mothers' experiences of client-centred flexible planning in home-based postpartum care: A promising tool to meet their diverse and dynamic needs

OBJECTIVE

To explore mothers' perspectives and experiences when facilitating greater flexibility in the planning range of home-based postpartum care, as an innovative tool to more client-centred care.

DESIGN

A qualitative study design with semi-structured in-depth interviews.

SETTING

The study was executed in collaboration with a postpartum care organisation in the Netherlands. It was part of a larger research project that studied the health effects of a new way of planning home-based postpartum care. This so-called 'flexible planning' made spreading and pausing of care possible up to the 14^th day postpartum instead of the standard care planning up to the 8^th day postpartum.

PARTICIPANTS

Mothers eligible to be interviewed for this study were participants of the larger research project who were allowed to plan their care according to the flexible planning. Twenty-one mothers were recruited through purposive sampling, of which ten were first-time mothers.

FINDINGS

Mothers valued the flexible planning as the timing of care could be tailored to their personal preferences and contexts. Yet, two main challenges were found: 1. mothers experienced difficulties in communicating and translating their dynamic needs into a care planning and 2. they felt discomfort in assigning tasks to care workers. Besides, our findings showed that care workers' practical as well as their emotional support (i.e. 'doing' vs. 'being') are greatly important in responding to mothers' needs.

KEY CONCLUSIONS

A flexible planning is a promising tool to facilitate more client-centred care in the postpartum care period. Yet, the hectic and overwhelming nature of the first few postpartum days can complicate the forward planning of care. In addition, not knowing what to expect from the postpartum care period and having a main focus on care workers 'doing' can lead to unclear and undesired working relations.

IMPLICATIONS FOR PRACTICE

When planning care in practice, a dialogue should be held between care workers and parents in which both their fields of expertise are respected. Above all, our study elucidated that novel care innovations like ours need to be co-created directly from the start with all involved parties to truly be successful.

The unintended consequences of client-centred flexible planning in home-based postpartum care: a shift in care workers' tasks and responsibilities

OBJECTIVE

To explore care workers' experiences with a flexible planning of home-based postpartum care as an innovative instrument to facilitate more client-centred care.

DESIGN

A mixed-methods design with a primarily qualitative approach followed by a quantitative follow-up, according to the Priority-Sequence model.

SETTING

This study is part of a larger research project researching the health effects of a flexible planning in postpartum care. The new planning enables clients and care workers to spread and/or pause the care over 14 days postpartum instead of the standard planning of eight to ten consecutive days.

PARTICIPANTS

Maternity home care workers who provide care according the flexible planning. Eight care workers were interviewed, another eight care workers participated in the focus group discussion, and 59 care workers filled in the survey.

FINDINGS

Two main unintended consequences of the flexible planning were found: 1. care workers experienced an undesirable 'shift in their tasks' along the course of the postpartum period and 2. were heavily worried about 'making enough contracted hours'. Consequently, care workers unwillingly performed much more domiciliary activities compared to the standard planning, especially during the final days of care.

KEY CONCLUSIONS

The predominant nursing tasks and responsibilities of care workers appeared insufficient to respond to clients' altering needs. In addition, shorter working days and on-call duties caused an undesired excessive high-level of flexibility among care workers. Consequently, care was paradoxically determined by organisational structures rather than clients' individual needs.

IMPLICATIONS FOR PRACTICE

Our study elucidated that co-creation together with health professionals is a prerequisite for successfully implementing innovations as their way of working and personal lives are profoundly affected.

Factors associated with maternal postpartum fatigue: an observationalstudy

OBJECTIVES

To assess the prevalence of postpartum fatigue at 10 days, 1 month and 3 months, and to describe the sociodemographic and clinical characteristics of women with fatigue and the associations with infant characteristics, maternal-infant attachment, and partner and midwifery support.

SETTING

Maternity care in England. Secondary analysis of 2014 National Maternity Survey.

PARTICIPANTS

Participants were a random sample of 10 000 women selected by the Office for National Statistics using birth registration records. Women aged less than 16 years or if their baby had died were excluded. Questionnaires were sent to women at 3 months post partum and asked about well-being and care during pregnancy, labour, birth and post partum. Specifically, women were asked whether they experienced fatigue/severe tiredness at 10 days, 1 month or 3 months post partum. Responses were received from 4578 women (47% response rate).

RESULTS

Decreasing but substantial proportions of women, 38.8%, 27.1% and 11.4%, experienced fatigue/severe tiredness at 10 days, 1 month and 3 months, respectively. These figures varied significantly by maternal age, level of deprivation, education and parity. Women reporting depression, anxiety, sleep problems and those breast feeding were at significantly increased risk (eg, OR for depression in women with fatigue at 3 months: 2.99 (95% CI 2.13 to 4.21)). Significantly more negative language was used by these women to describe their babies, and they perceived their baby as more difficult than average (eg, two or more negative adjectives used by women with fatigue at 3 months: OR 1.86 (95% CI 1.36 to 2.54)). Women with postpartum fatigue had greater partner support but were significantly less likely to report seeing the midwife as much as they wanted.

CONCLUSIONS

Postpartum fatigue is not inevitable or universal, although early in the postnatal period it affects a substantial proportion of women. Predictors include age and parity, but practical help and support from partners and midwives may be protective factors.

Policy, evidence and practice for post-birth care plans: a scoping review

BACKGROUND

Postnatal care continually attracts less attention than other parts of the childbirth year. Many regions consistently report poor maternal satisfaction with care in the post-birth period. Despite policy recommending post-birth planning be part of maternity services there remains a paucity of empirical evidence and reported experience using post-birth care plans. There is a need to report on post-birth care plans, identify policy and guideline recommendations and gaps in the current empirical research, as well as experiences creating and using post-birth care plans.

METHODS

This scoping review accessed empirical literature and government and professional documents from 2005 to present day to build a picture of current understanding of policy imperatives and existent published empirical evidence. The review was informed by the Arksey and O'Malley approach employing five stages.

RESULTS

The review revealed that post-birth care planning is promoted extensively in health policy and there is emergent evidence for its implementation. Yet there is a paucity of practice examples and only one evaluation in the UK. The review identified four overarching themes: 'Positioning of post-birth care planning in policy; 'Content and approach'; 'Personalised care and relational continuity'; Feasibility and acceptability in practice'.

CONCLUSIONS

Empirical evidence supports post-birth care planning, but evidence is limited leaving many unanswered questions. Health care policy reflects evidence and recommends implementation of post-birth care plans, however, there remains a paucity of information in relation to post-birth care planning experience and implementation in practice. Women need consistent information and advice and value personalised care. Models of care that facilitate these needs are focused on relational continuity and lead to greater satisfaction. It remains unclear if a combination of post-birth care planning and continuity of carer interventions would improve post-birth outcomes and satisfaction. Gaps in research knowledge and practice experience are identified and implications for practice and further research suggested.

MyHEART: A Non Randomized Feasibility Study of a Young Adult Hypertension Intervention

BACKGROUND

In the United States, young adults (18-39 year-olds) have the lowest hypertension control rates (35%) compared to middle-aged (58%) and older (54%) adults. Ambulatory care for hypertension management often focuses on medication with little time for self-management and behavioral counseling. This study was designed to evaluate the feasibility of MyHEART, a telephone-based health coach self-management intervention for young adults. The goals were to determine the intervention's ability to: 1) recruit young adults with uncontrolled hypertension, 2) maintain ongoing communication between the coach and participants, 3) increase participants' engagement in self-management, 4) document coach-patient communication in the electronic health record, and 5) assess patient acceptability.

METHODS

Eligible participants were identified through the electronic health record. Inclusion criteria included 18-39 year-olds, with ICD-9 hypertension diagnoses and uncontrolled hypertension (≥ 140/90 mmHg), receiving regular primary care at a large multispecialty group practice. The intervention consisted of 6 telephone self-management sessions by a health coach targeting lifestyle modifications. Patients completed an open-ended acceptability survey.

RESULTS

Study uptake was 47% (9 enrolled/19 eligible). Mean (SD) age was 35.8 (2.6) years, 78% male, and 33% Black. Over 85% of enrolled young adults maintained communication with their health coach. At baseline, 11% reported checking their blood pressure outside of clinic; 44% reported blood pressure monitoring after the study. All coach-patient encounters were successfully documented in the electronic health record for primary care provider review. Open-ended responses from all surveys indicated that participants had a positive experience with the MyHEART intervention.

CONCLUSIONS

This study demonstrated that MyHEART was feasible and acceptable to young adults with uncontrolled hypertension. Health coaches can effectively maintain ongoing communication with young adults, document communication in the electronic health record, and increase engagement with home blood pressure monitoring. The results of this study will inform a multi-center young adult randomized controlled trial of MyHEART.