New parents’ experiences of postnatal care in Sweden
Article Outline
- Summary
- Introduction
- Method
- Results
- Socio-demographic background
- Models of postnatal care
- Satisfaction with postnatal care
- Socio-demographic background and pregnancy outcome in relation to satisfaction
- The content of postnatal care in relation to satisfaction
- Staff related variables in relation to dissatisfaction with postnatal care
- Multivariate analysis
- Fathers’ involvement in postnatal care
- Fathers who did not stay overnight
- Fathers’ satisfaction with the content of postnatal care
- Discussion
- Acknowledgements
- References
- Copyright
Summary
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.
Keywords: Postnatal care, Patient satisfaction, Parents
Introduction
Postnatal care in Sweden is mainly hospital based, and in recent years the length of postpartum stay has decreased. In the late 1980s “early discharge” (<72
h) was introduced in some places, with midwives making home visits to the new family.1 This care model was established in many Swedish hospitals and the average length of stay after a normal birth is now 2.5 days, a decrease from 6 days in 1973.2 In larger cities, women are often encouraged to go home within the first 24h. After birth, women in Sweden are typically cared for in a postpartum unit, where they may share a room with other women or in some hospitals be moved to a family unit where their partner can stay overnight. A few hospitals have “patient hotels” for women with uncomplicated pregnancies and normal births.
The research literature on postnatal care has mostly focused on issues such as length of hospital stay,3, 4, 5, 6 breast-feeding5, 7 and provision of information.8, 9 In a review of 138 papers related to postpartum care and published in peer-reviewed journals, 41 studies were related to breast-feeding, 31 to the management of postpartum perineal or uterine pain and 66 to other areas such as postpartum support, early discharge, depression and anxiety.10
Evaluations of satisfaction with care have established that patients in general are satisfied, which is also true in relation to the maternity services.3, 11, 12, 13, 14 Many studies have reported less satisfaction with postnatal care than that provided during labour and birth.11, 12, 13, 14, 15 Few studies have, however, focused solely on satisfaction with postnatal care, but attitudes and behaviour of staff are reported being the most important of new mothers’ overall rating of postnatal care.16, 17 New fathers’ experiences of postpartum care are rarely studied, but some authors have reported the importance of viewing the couple and their newborn as a unit18 and the fact that hospital routines can hinder the father's interaction with his child.19 One of the most important aspects of postnatal care reported by women in a national Swedish survey was the father's opportunity of staying overnight in the postpartum ward.20
Childbearing women are not really ‘sick’ but undergo care activities during and shortly after pregnancy. They are active participants in the same way as patients in receipt of primary care. Prospective and new fathers in Sweden are also involved in care activities, as they are invited and expected to participate during the antenatal visits, attend the birth and in some hospitals have the option to stay with the woman and the newborn baby after birth. The new fathers are also encouraged by society to take parental leave, and 2 months out of the 450-day paid parental leave are exclusively allocated to fathers.
The aim was to study new parents’ satisfaction with postnatal care and to estimate the proportion of fathers who are given the opportunity of staying overnight at the postnatal ward. The hypothesis was that the following factors were related to new parents’ experiences of postnatal care:
Method
Design
This study focuses on new parents’ experiences of postnatal care. The hospital in which the study took place is located in the northern part of Sweden and has an annual birth rate of approximately 1600. At the time of the investigation a traditional postnatal ward was available, but the new mothers could choose early discharge and were offered home visits from a special group of postnatal midwives who also arranged for visits to the hospital, within a week, for paediatric examination. If the baby was transferred to the neonatal intensive care unit (NICU), mothers could sometimes have co-care of the newborn, but her own medical care was the responsibility of the traditional postnatal ward staff, who visited the NICU once or twice a day. Partners were allowed to stay overnight if the woman had a single room.
Participants
Women who gave birth to a live baby during a 3.5-month period in 2004 were identified through the delivery ward register. They were sent a letter of invitation, in which the purpose of the study was described, together with a questionnaire and a stamped addressed envelope, 6 months after childbirth. A completed and returned questionnaire was viewed as informed consent. In order not to contact mothers whose babies might have died after hospital discharge or who had a serious illness, all child health clinics and neonatal/paediatric wards in the area were contacted before approaching the mothers. Two reminders were sent to non-responders. The partners were invited to complete a small section of the mother's questionnaire. The study was approved by the Regional Research and Ethics Committee of Umeå University, reg. no. 04-134 M and by the Head of the Obstetric Department at the hospital.
The questionnaire
The main focus of the questionnaire was postnatal care, but information about the parents’ socio-demographic background as well as about the pregnancy and birth was also collected. The outcome variable, satisfaction with postnatal care, was assessed on a five-point scale ranging from “very dissatisfied” to “very satisfied”, as were most of the other explanatory variables. Issues related to postnatal care were; satisfaction with information, with postnatal checks, with structural aspects of care, the partner's role and with staff working on the postnatal ward.
Analysis
The analysis was performed in two steps. First, the relative risk associated with the different categories of independent variables was calculated as the ratio between the percentage of mothers who were satisfied and dissatisfied in their overall assessment of postnatal care. A 95% confidence interval for the relative risk was estimated using a method described by Mantel and Haentzel.21 Secondly, the statistically significant relevant variables in the bivariate analysis were thereafter tested by means of logistic regression analysis in order to adjust the estimated relative risks to take account of the influence of potential confounders (socio-demographic background, length of pregnancy, mode of delivery, complications and postnatal care model).
Results
During the study period, 503 new mothers met the inclusion criteria and were sent a questionnaire. Twelve of them had moved and could not be reached. Of the 491 eligible new mothers, 294 (60%) completed and returned the questionnaire. Two hundred and eighty partners (all male) (57%) chose to complete the father's section of the questionnaire. Women who did not return the questionnaire were more likely to be multiparas (RR 1.6; 1.2–2.0) and to have a non-Swedish name (RR 1.6; 1.2–2.1). No differences in age, residential area and mode of delivery were found between women who returned the questionnaire and those who did not.
Socio-demographic background
The mean age of the new mothers was 31 years and the fathers 33 years (Table 1). More mothers were under 25 years, compared to the fathers (RR 1.3; 1.0–1.6). A similar number of parents had had their first baby. Only a few women reported being single or living apart from their partner, while the majority were married or cohabiting. Most of the respondents were born in Sweden but 17 mothers (6%) and 11 fathers (4%) were born in other countries. The new mothers were more likely to have a university education compared to the fathers (RR 1.2: 1.1–1.5).
Table 1. Socio-demographic background
| New mothers n=294 (n (%)) | New fathers n=280 (n (%)) | |
|---|---|---|
| Age mean (range, years) | 30.6 (16–42) | 32.9 (20–57) |
| Age groups | ||
| <25 years | 41 (13.9) | 20 (7.1) |
| 25–35 years | 199 (67.7) | 180 (64.3) |
| >35 years | 54 (18.4) | 80 (28.6) |
| Marital status | ||
| Married/cohabiting | 280 (95.2) | 274 (98.6) |
| Not living together with partner | 5 (1.7) | 3 (1.0) |
| Single | 9 (3.1) | 1 (0.3) |
| Country of birth | ||
| Sweden | 275 (94.2) | 265 (96.0) |
| Other | 17 (5.8) | 11 (4.0) |
| Level of education | ||
| Compulsory school, grades 1–9 | 10 (3.4) | 13 (4.7) |
| High school, grades 1–3 | 149 (50.9) | 175 (62.7) |
| College/university | 134 (45.7) | 91 (32.6) |
| Profession | ||
| Health services | 49 (18.0) | 9 (3.4) |
| Child care and social work | 25 (9.2) | 3 (1.1) |
| Culture | 0 | 3 (1.1) |
| Business, law | 42 (15.4) | 28 (10.6) |
| White collar occupation | 50 (18.4) | 28 (10.6) |
| Technical work and IT | 23 (8.4) | 69 (26.2) |
| Teaching | 27 (9.9) | 16 (6.1) |
| Traditional male occupations | 3 (1.1) | 50 (19.0) |
| Service occupations | 21 (7.7) | 26 (9.9) |
| Other occupations | 18 (6.6) | 24 (9.1) |
| Unemployed | 14 (5.1) | 7 (2.7) |
| Residential area | ||
| Large city | 199 (67.7) | 189 (67.5) |
| Small city | 39 (13.3) | 39 (13.9) |
| Large municipality | 36 (12.2) | 35 (12.5) |
| Small municipality | 15 (5.1) | 13 (4.6) |
| Other | 5 (1.7) | 4 (1.4) |
| Number of children | ||
| One child | 140 (47.9) | 127 (46.5) |
| Two children | 101 (34.6) | 98 (35.9) |
| Three children | 35 (12.0) | 36 (13.2) |
| Four or more children | 16 (5.5) | 12 (4.4) |
Models of postnatal care
Table 2 shows that the average length of stay was 3.0 days and half of the women reported that they had availed ‘themselves’ of the early discharge option (within 72h after birth). It was less common for first-time mothers to opt for early discharge, compared to mothers with more than one child (RR 0.6; 0.5–0.8). Of those who chose early discharge (n=141), 46 (33%) received home visits from a midwife on one or two occasions. Most women were satisfied with the time of discharge and the number of home visits.
Table 2. Postnatal care
| Total n=294 (n (%)) | Primiparas n=141 (n (%)) | Multiparas n=153 (n (%)) | |
|---|---|---|---|
| Model of postnatal care | |||
| Traditional postnatal ward | 134 (45.6) | 82 (58.2) | 52 (34.0) |
| Early discharge | 138 (46.9) | 45 (31.9) | 93 (60.8) |
| Co-care neonatal ward | 22 (7.5) | 14 (9.9) | 8 (5.2) |
| Length of postnatal stay (mean, S.D.) | 3.0 (1.5) | 3.3 (1.2) | 2.7 (1.7) |
| Views about length of postnatal stay | |||
| Too short | 24 (8.4) | 8 (5.9) | 16 (10.6) |
| Just about right | 242 (84.6) | 121 (89.6) | 121 (80.1) |
| Too long | 20 (7.0) | 6 (4.4) | 14 (9.3) |
| Number of home visits received | |||
| One | 40 (93.0) | 17 (89.5) | 23 (95.8) |
| Two | 3 (7.0) | 2 (10.5) | 1 (4.2) |
| Views about number of home visits received | |||
| Too few | 7 (16.3) | 4 (22.3) | 3 (12.0) |
| Just about right | 36 (83.7) | 14 (77.7) | 22 (88.0) |
Satisfaction with postnatal care
In their overall assessment, most of the mothers (66%) were satisfied with the postnatal care they had received, 72% were satisfied with the medical aspects and 50% with the emotional aspects (Table 3). The following the paper will focus on the overall assessment of postnatal care.
Table 3. Women's assessment of their postnatal care
| Medical aspects of postnatal care | Emotional aspects of postnatal care | Overall assessment of postnatal care | |
|---|---|---|---|
| Satisfied (%) | 72 | 50 | 66 |
| Dissatisfied (%) | 28 | 50 | 34 |
Socio-demographic background and pregnancy outcome in relation to satisfaction
None of the socio-demographic variables were associated with overall satisfaction with postnatal care or with the course of pregnancy and birth.
The content of postnatal care in relation to satisfaction
Early discharge was not associated with dissatisfaction, but women who had co-care at the NICU department were more dissatisfied in their overall assessment of the postnatal care received (Table 4). Length of hospital stay was related to dissatisfaction when the women viewed the stay as too short or too long. Dissatisfaction with postnatal care was also related to lack of information about all issues, the strongest associations being the child's needs and breast-feeding. Women who were dissatisfied with the postnatal care received were unhappy with the postnatal checks both for themselves and their baby and complained about the environment and visiting hours. Factors related to the partner were also strongly associated with dissatisfaction, and women who were dissatisfied considered that their partner was not involved in the care. Lack of opportunity for the partner to stay overnight was strongly related to dissatisfaction (Table 4).
Table 4. The content of postnatal care in relation to overall satisfaction
| Satisfied n=192 (n (%)) | Dissatisfied n=97 (n (%)) | Relative risk of dissatisfaction (95% CI) | |
|---|---|---|---|
| Model of postnatal care | |||
| Traditional postnatal ward | 91 (68.4) | 42 (31.6) | 1.0 Ref. |
| Early discharge | 91 (67.4) | 44 (32.6) | 1.0 (0.7–1.5) |
| Co-care neonatal ward | 9 (45.0) | 11 (55.0) | 1.7 (1.1–2.8) |
| Views about length of stay | |||
| Too short | 12 (50.0) | 12 (50.0) | 1.8 (1.2–2.9) |
| Just about right | 173 (72.7) | 65 (27.3) | 1.0 Ref. |
| Too long | 4 (21.1) | 15 (78.9) | 2.9 (2.1–3.9) |
| Informationa | |||
| About physical changes | |||
| Satisfied | 110 (83.3) | 22 (16.7) | 1.0 Ref. |
| Dissatisfied | 66 (55.9) | 52 (44.1) | 2.6 (1.7–4.1) |
| About emotional changes | |||
| Satisfied | 72 (84.7) | 13 (15.3) | 1.0 Ref. |
| Dissatisfied | 82 (70.7) | 34 (29.3) | 1.9 (1.1–3.4) |
| About breast-feeding | |||
| Satisfied | 133 (84.7) | 24 (15.3) | 1.0 Ref. |
| Dissatisfied | 48 (43.2) | 56 (53.8) | 3.5 (2.3–5.3) |
| About sexual matters | |||
| Satisfied | 71 (84.5) | 13 (15.5) | 1.0 Ref. |
| Dissatisfied | 73 (66.4) | 37 (33.6) | 2.2 (1.2–3.8) |
| About the child's needs | |||
| Satisfied | 132 (84.1) | 25 (15.9) | 1.0 Ref. |
| Dissatisfied | 42 (42.9) | 56 (57.1) | 3.6 (2.4–5.3) |
| Postnatal checks | |||
| Of the woman | |||
| Satisfied | 136 (80.5) | 33 (19.5) | 1.0 Ref. |
| Dissatisfied | 56 (46.7) | 64 (53.3) | 2.7 (1.9–3.9) |
| Of the baby | |||
| Satisfied | 180 (71.4) | 72 (28.6) | 1.0 Ref. |
| Dissatisfied | 12 (32.4) | 25 (67.6) | 2.4 (1.8–3.2) |
| Structural aspectsb | |||
| The environment on the ward | |||
| Satisfied | 121 (80.1) | 30 (19.9) | 1.0 Ref. |
| Dissatisfied | 70 (51.19 | 67 (48.9) | 2.5 (1.7–3.5) |
| Visiting hours | |||
| Satisfied | 127 (73.8) | 45 (26.2) | 1.0 Ref. |
| Dissatisfied | 40 (49.4) | 41 (50.6) | 1.9 (1.4–2.7) |
| Partner involvement in the care | |||
| Satisfied | 109 (79.0) | 29 (21.0) | 1.0 Ref. |
| Dissatisfied | 70 (53.0) | 62 (47.0) | 2.2 (1.5–3.2) |
| Partner's opportunity to stay overnight | |||
| Satisfied | 114 (76.0) | 36 (24.0) | 1.0 Ref. |
| Dissatisfied | 49 (51.0) | 47 (49.0) | 2.0 (1.4–2.9) |
a32–93 women reported not receiving any information. |
b20–42 women reported ‘not applicable’. |
Staff related variables in relation to dissatisfaction with postnatal care
The behaviour and the characteristics of the postnatal staff were strongly associated with dissatisfaction with postnatal care. If the women experienced lack of support from the staff they were nearly six times more likely to be dissatisfied, followed by a fivefold risk if they were treated in an unfriendly fashion (Table 5).
Table 5. Variables related to characteristics of staff in relation to satisfaction
| Satisfied n=192 (n (%)) | Dissatisfied n=97 (n (%)) | Relative risk of dissatisfaction (95% CI) | |
|---|---|---|---|
| Support from staff | |||
| Satisfied | 171 (86.4) | 27 (13.6) | 1.0 Ref. |
| Dissatisfied | 21 (23.1) | 70 (76.9) | 5.6 (3.9–8.1) |
| Friendly and helpful staff | |||
| Satisfied | 181 (82.6) | 38 (17.4) | 1.0 Ref. |
| Dissatisfied | 10 (14.5) | 59 (85.5) | 4.9 (3.6–6.9) |
| Instructions about how to nurse the baby | |||
| Satisfied | 115 (80.4) | 28 (19.6) | 1.0 Ref. |
| Dissatisfied | 55 (55.0) | 45 (45.0) | 2.3 (1.5–3.4) |
| Practical breast-feeding support | |||
| Satisfied | 114 (83.8) | 22 (16.2) | 1.0 Ref. |
| Dissatisfied | 52 (49.1) | 54 (50.9) | 3.1 (2.0–4.8) |
| Help with the baby | |||
| Satisfied | 115 (82.1) | 25 (17.9) | 1.0 Ref. |
| Dissatisfied | 44 (45.4) | 53 (54.6) | 3.1 (2.0–4.6) |
| Opportunity to rest without being disturbed | |||
| Satisfied | 113 (77.9) | 32 (22.1) | 1.0 Ref. |
| Dissatisfied | 39 (54.1) | 61 (45.9) | 2.7 (1.9–3.9) |
Multivariate analysis
All the significant variables from the bivariate analysis were included in a logistic regression model. After adjusting for possible confounders, the result showed that the strongest factors related to dissatisfaction with postnatal care were unfriendly and unhelpful staff and lack of support from staff. Of the structural aspects, only the lack of opportunity for the partner to stay overnight at the hospital remained in the model, together with dissatisfaction with postnatal checks for the woman herself and insufficient practical breast-feeding support (Table 6).
Table 6. Logistic regression model of variables associated with dissatisfaction with overall postpartum care
| Crude RR 95% CI | Adjusted RR 95% CIa | |
|---|---|---|
| Unfriendly and unhelpful staff | 10.2 (3.7–28.2) | 10.3 (3.2–32.8) |
| Dissatisfied with support from staff | 4.2 (1.8–9.9) | 6.4 (2.3–17.5) |
| New father not allowed to stay over night | 3.7 (1.7–8.1) | 5.2 (1.8–14.5) |
| Dissatisfaction with postnatal checks (woman) | 2.6 (1.2–5.6) | 2.6 (1.1–6.3) |
| Not enough practical breast-feeding support | 1.5 (1.1–1.9) | 1.6 (1.2–2.1) |
aModel adjusted for socio-demographic background, length of pregnancy, mode of delivery, complications, care model and length of postnatal stay. |
Fathers’ involvement in postnatal care
Of the 280 new fathers who completed the questionnaire, 176 (63%) reported that they were offered the opportunity to stay overnight on the postnatal ward, the majority in the same room as their partner, although ten fathers had to sleep in another room. Of those who were offered this option, 72% accepted, while 27 were unable or did not want to stay, and a further 23 had to take care of older children at home.
Fathers who did not stay overnight
Fathers with older children were less likely to stay overnight compared to first-time fathers (RR 3.6; 2.0–4.5), which was also the case with fathers over the age of 35 years (RR 1.8; 1.3–2.4). Fathers with low educational level were less likely to stay (RR 1.7; 1.3–2.4) as were those living in a ‘blue-collar’ area (RR 1.6; 1.2–2.2).
Fathers’ satisfaction with the content of postnatal care
In general, there were no major differences in satisfaction with information between fathers who stayed overnight and those who did not, although fathers who did not spend the night on the postnatal ward more often reported that they had not received any information about breast-feeding (RR 2.0; 1.4–2.8) or the child's needs (RR 1.6; 1.2–2.2) and that they lacked knowledge about the postnatal checks (RR 2.2; 1.6–2.9). A higher proportion of fathers who did not stay overnight were dissatisfied with visiting hours (RR 1.6; 1.2–2.2), with their opportunity to be involved in the care (RR 1.8; 1.3–2.6) and to stay overnight (RR 3.1; 2.2–4.4). They were also more dissatisfied with support from staff (RR 1.5; 1.1–2.0) and with the provision of assistance and relief (RR 1.5; 1.1–2.2).
Discussion
In this local hospital based study, more than one woman in three were dissatisfied with postnatal care, half were dissatisfied with the emotional aspects and more than one in four with the medical aspects, which also includes the midwifery care such as postnatal checks. Compared to a national sample of Swedish-speaking women surveyed in 1999–2000,13 women who attended this local hospital were significantly more dissatisfied with emotional aspects (RR 1.3; 1.1–1.4, p=0.0006) and the overall care (RR 1.3; 1.1–1.5, p=0.000). It is possible that postnatal care has changed since the year 2000, mainly in terms of a shorter length of stay after childbirth, which could be one explanation for the differences. In comparison with international studies, mainly from Australia, the satisfaction scores in this study are low. Brown et al.17 measured satisfaction with postnatal care in the state of Victoria and found that 49% rated their postnatal care as less than “very good”. Using the same cut-off level as in Brown et al.'s study, only 18% of the mothers who received postnatal care at the hospital in the present investigation would be satisfied.
In common with other research findings,13, 17, 22, 23 most of the factors associated with dissatisfaction were related to staff. Friendly and helpful staff that provides support, assistance and adequate information would increase satisfaction with postnatal care. All these factors are related to the interaction between caregivers and new mothers. However, the amount of care available for new parents is probably related to staff members’ working conditions. In many Swedish hospitals early discharge (within 3 days after birth) is now standard for women with normal pregnancies and births. This creates a rapid patient flow, which could lead to the staff becoming rushed and stressed. In an Australian survey of postnatal staff, the result showed that the staff–patient ratios were far below the recommended level, which means that staff members are more exposed to stress. Some of the problems highlighted were viewing postnatal care as less important than intrapartum care and the recruitment of permanent staff.24
The third associated factor in the logistic regression model of women's dissatisfaction with postnatal care was the father not being offered the option of staying overnight. This was also reported by the fathers themselves as grounds for dissatisfaction. A previous Swedish study showed that allowing fathers to stay overnight at the postnatal ward, for example in a postnatal family ward, reduced the risk of dissatisfaction with postnatal care.13 In the present study more than half of the fathers were given the opportunity to stay overnight in the postnatal ward. More fathers over 35 years and those who had other children were less likely to avail of this opportunity, probably due to their family situation. However, fathers with a low level of education and those living in a ‘blue-collar’ area were also less likely to spend the night on the postnatal ward, which could indicate more traditional gender roles. Encouraging fathers to become involved in their child's life at an early stage could possibly make them use more of their parental leave, which has been shown to reduce fathers’ mortality25 and the rate of divorce/separation.26 In this study, the fathers who stayed overnight reported receiving more information about breast-feeding and child care than those who did not, which could be beneficial, as it is known that partner support plays an important role in the initiation and duration of breast-feeding.7
Fathers who were not offered the option of staying overnight or who did not choose to or were unable to avail of this opportunity were more likely to be dissatisfied with this as well as with their lack of involvement in the care. This is in line with previous studies of women's experiences of postnatal care, where women valued postnatal care in family oriented postnatal wards and stressed the importance of giving the father the option of staying overnight.13, 20 Similar findings have also been reported in antenatal care research, in which one of the most important factors mentioned by women was partner involvement in the care during pregnancy.27 The midwife's inability to recognize the partner's needs was strongly associated with dissatisfaction with antenatal care.28 Making postnatal care a ‘family event’, and not merely medical treatment after labour and delivery, would probably better meet parents’ needs, as previously shown by Fredriksson et al.18
Another significant factor related to dissatisfaction with postnatal care was lack of maternal postnatal checks. There is insufficient evidence regarding many of the routine practices in hospitals. In a survey of Swedish postnatal wards in 2006, 20% reported having no routine maternal observations.29 Only 20% of maternity wards in Swedish hospitals checked the involution of the uterus. In an Australian survey this was done on all mothers.30 Encouraging women to use early discharge options could have disadvantages in terms of less confident mothers. A return visit, the purpose of which is to check the baby's health, may not be enough. Home visits from an experienced midwife would probably increase satisfaction as well as allowing new mothers time to discuss their own situation, for example health problems and the adjustment to motherhood. A regional Swedish study showed that the care model with home visits from a midwife after early discharge is appreciated and considered safe by new parents.31
Insufficient practical breast-feeding support was also associated with dissatisfaction. Providing such information has been reported as difficult by postnatal staff in Swedish hospitals in 2006.29 Despite the fact that it can be difficult to teach breast-feeding, the high breast-feeding rate (91%) at 2 months in Sweden in 2004 (77% exclusively and 14% some breast-feeding)32 is a good example of mothers’ willingness to give their babies the best possible start.
Strengths and limitations
One of the strengths of this study is its ‘family oriented’ approach that includes new mothers and new fathers. We do not know, however, whether they answered the different sections of the questionnaire as a couple or individually. The same questionnaire was used, as it was not possible to contact new fathers directly, due to the fact that they are not registered as “patients” in hospital records. The response rate of 60% is fairly good and comparable to all eligible women in the national Swedish survey,13 but could perhaps have been improved by, for example, a telephone reminder.33 Women who did not respond to the questionnaire were more often multiparas, with a non-Swedish sounding name. It is possible that contacting only Swedish-born women might have increased the response rate but would have excluded the foreign-born women who actually completed the questionnaire. The cut-off point chosen in the dichotomization of satisfaction could have affected the results. The reason for employing this cut-off was mainly the possibility to compare the results with the national Swedish sample.13 Using the cut-off suggested by Brown, et al.17 and Collins and O’Cathain34 and assessing postnatal care as ‘very good’ and ‘less than very good’ would probably have resulted in more dissatisfied mothers but with the same associated factors. Another limitation is the time at which the parents were contacted, namely 6 months after childbirth. There are conflicting reports about the right time at which to measure satisfaction. Some authors have shown that the memory of childbirth is clear for up to 20 years after the event,35 while on the other hand it has been revealed that people tend to be more negative at a later stage, even after 1 year.36 Asking about overall satisfaction usually results in more positive responses than asking for detailed information.37 Both types of measure were used in the present study; satisfaction with the different aspects of postnatal care at the beginning and overall satisfaction at the end of the questionnaire.
Most of the hypotheses were confirmed with the exception of the assumption that satisfaction is influenced by socio-demographic factors. In the national Swedish study,13 single status and low level of education were associated with less satisfaction with postnatal care. Compared to women recruited in 1999–2000, the present sample did not differ in terms of civil status, but there was a tendency towards different levels of education, with fewer women having compulsory school only (3.4% versus 6.2%) and more women reporting university level (45.7% versus 38%). This could, however, be explained by the general increase in level of education in Sweden38 or by the smaller sample size. Another hypothesis that satisfaction with postnatal care is associated with labour outcome, mainly mode of delivery, was not confirmed. However, mothers who had co-care of their baby at the NICU were more likely to be dissatisfied with their postnatal care. This is in line with findings from the national survey13 where births (vaginal or emergency CS), after which the baby was transferred to a neonatal intensive unit, were associated with dissatisfaction with postnatal care.
Conclusions and recommendations for clinical practice
Based on the results of this study, staff working in postnatal care must become aware of the needs of the new family and improve patient–staff interactions such as support and assistance to new parents on the postnatal ward, in order to enhance patient satisfaction. New parents value caregivers who are sensitive, helpful, and listen to them. Family oriented postnatal care is essential, which involves giving fathers the opportunity to stay overnight and participate in the care of the newborn baby.
Acknowledgements
The study was funded by the county council of Västernorrland, Mid-Sweden University and the Karolinska Institutet, Sweden.
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PII: S1871-5192(07)00058-3
doi:10.1016/j.wombi.2007.06.001
© 2007 Australian College of Midwives. Published by Elsevier Inc. All rights reserved.
