Time to listen: Strategies to improve hospital-based postnatal care☆

Article Outline

• Summary
• 1. Introduction
• 2. Methods
  • 2.1. The setting
  • 2.2. Phase One—‘identification of the problem’
  • 2.3. Phase Two—‘planning’
  • 2.4. Data analysis
• 3. Results
  • 3.1. Phase One—midwives’ perceptions of quality postnatal care
    • 3.1.1. Building a trusting relationship
    • 3.1.2. Meeting the individual needs of women
    • 3.1.3. Meeting the emotional and practical needs of women
    • 3.1.4. Ensuring the safety and health of mother and baby
    • 3.1.5. Factors that facilitated quality care
    • 3.1.6. Factors that hindered quality care
  • 3.2. Phase Two—designing strategies to improve hospital-based postnatal care
  • 3.3. The key strategy—‘One-to-One time’
    • 3.3.1. The Parenting Room
    • 3.3.2. Providing opportunity to rest and recuperate
  • 3.4. Training and support for midwives
• 4. Discussion
• 5. Conclusion
• Acknowledgements
• References
• Copyright

Summary 

Background

In Australia and internationally, women report high levels of dissatisfaction with hospital-based postnatal care.

Aim

To design and implement strategies to improve hospital-based postnatal care at a Sydney metropolitan hospital.

Method

This was an Action Research study. In Phase One, midwives considered the literature and participated in group discussions and interviews to determine their perceptions of postnatal care and the factors that facilitate or hinder the provision of quality care. In Phase Two, midwives participated in 12 working group meetings to design strategies to improve care.

Results

Several important principles of postnatal care were described, including building a relationship with women, meeting their individual needs, being flexible in approach and providing continuity of care. ‘Listening to women’, ‘being there,’ and ‘normalising experiences and expectations’ were believed to be critical to achieving these principles. A key strategy ‘One to One Time’ was designed to provide women with an uninterrupted period of time each day with a midwife who was available to listen to their needs and concerns and discuss issues related to their health and that of their baby.

Conclusion

Midwives designed and implemented strategies that they believed would improve in-hospital postnatal care.

Keywords: Postnatal care, Women's health, Midwifery, Health services research, Communication, Assessment of health care needs

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1. Introduction 

Over the past decade a number of studies have identified women's dissatisfaction with postnatal care. In particular, women report high levels of dissatisfaction with hospital-based postnatal care including: lack of rest; lack of consistent advice; the perception that midwives are too busy; inadequate time available to ask questions; inappropriate or non-individualised advice; too much information provided in a short period; and the short and fragmented nature of midwifery care.¹, ², ³, ⁴, ⁵, ⁶, ⁷ On discharge from hospital, women have reported: that they lack confidence, particularly for breastfeeding; are unprepared for physical or psychosocial problems they may encounter; and have little follow-up or community support.², ⁸ While several studies have investigated models of continuity of midwifery care⁶, ⁹ and community-based postnatal care,¹⁰ few have investigated strategies to improve the environment of the postnatal unit and the way postnatal care is provided by midwives in hospital.⁴, ⁵, ¹¹, ¹², ¹³

This paper reports on the first two phases of an action research study that aimed to engage midwives in the design and implementation of strategies to improve hospital-based postnatal care within current resources at a metropolitan hospital in Sydney. Action research involves cycles of activity that include: identifying or defining a problem or concern; planning and development of actions; implementation and evaluation and reflection.¹¹, ¹⁴ This paper presents the outcomes of the first two phases of the action research study describing:

Midwives experiences of implementing the strategies and outcomes for women will be presented in a separate paper.

The study contributes to the limited literature on innovation in hospital-based postnatal care by providing an insight into how one hospital attempted to improve the care for women by engaging midwives in a change process through action research. While studies of practice change in maternity settings are not unique, this study adds to the literature by highlighting the need for midwives to prioritise the often ‘taken for granted’ aspects of postnatal care particularly listening to women in order to address their individual needs and concerns.⁴, ⁵

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2. Methods 

2.1. The setting 

The study was conducted in a maternity unit at a public, metropolitan hospital in southern Sydney. The hospital services an urban population which is, in general, socio-economically advantaged compared to the state as a whole. It also has a large multicultural population with 31% of residents in the area born overseas and 25% of residents speaking a language other than English.

The maternity unit caters for approximately 2200 births per annum. The average length of postnatal stay during the period of data collection was 2.5 days and around 40% of women accessed a Midwifery Support Program (MSP) that is, discharge within 48h of birth. The MSP was not necessarily with a known caregiver. Some of the midwifery staff on the postnatal ward worked permanently in the postnatal area; others rotated around the unit. There were also two midwifery teams who had an identified group of clients and provided antenatal care in community-based clinics, 24h on-call service for labour and birth (in the hospital) and postnatal care for the morning shift in the postnatal ward. The postnatal ward has 18 beds. Four midwives, including a student midwife and a team midwife, were on a morning shift, with one allocated to be in charge plus a lactation support midwife, with three staff in the afternoon and three at night. There is also a ward clerk who worked office hours.

The staff in the maternity unit at the hospital had developed relationships with the researchers over the 3 years prior to the action research project because of research that had been conducted in the maternity unit.

The study received human research ethical approval from the South East Health Ethics Committee (Southern Sector).

2.2. Phase One—‘identification of the problem’ 

Midwives working in the postnatal ward formed an action research (working) group. At the start of the project, the participating midwives and the research facilitators (authors 1, 3, 4) discussed the international and national research about women's expectations of and satisfaction with postnatal care. The included the written summary of results from a survey of women who received postnatal care in the research hospital in the year prior to this study. The survey investigated the needs of women in the first few days after birth and their perceptions of care provided in the hospital and at home.

A total of 31 midwives then participated in discussion groups and interviews (facilitated by authors 1 and 3) to determine midwives’ perceptions of postnatal care and to identify the factors that facilitate or hinder the provision of quality care. All participants worked in the postnatal unit. Participants included midwives, managers, the lactation support midwife and educators. A total of five group discussions and six individual interviews with key stakeholders were held. Each focus group comprised five to nine participants and the focus groups and interviews lasted approximately 1h and were audio-tape recorded and transcribed. Key prompts focusing on midwives’ perceptions of quality postnatal care and the factors that facilitate care were used to guide the discussion.

2.3. Phase Two—‘planning’ 

In Phase Two, midwives and researchers used findings from Phase One to inform the design of strategies to improve care for women in the postnatal period. The 31 midwives who participated in Phase One, plus an additional five midwives who were new to the ward, participated in Phase Two of the study. These midwives participated in 12 action research group meetings over a 4-month period to develop the strategies for improving care. Meetings occurred every 7–10 days and were held on different days of the week to provide opportunities for all staff to participate, including night staff. There were four to six staff at each meeting and each midwife attended three working group meetings on average, with a group of 10 full time staff attending eight or more meetings. Minutes were taken at each meeting and distributed to staff and the researchers kept a field note diary to record outcomes from the meetings.

2.4. Data analysis 

Data were analysed using a thematic analysis to develop categories or themes. The following steps outlined by Liamputtong and Ezzy¹⁵ guided the analysis and are commonly used by researchers in the process of data analysis:

Quotes from participants are used to illustrate the themes and are in italics.

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3. Results 

3.1. Phase One—midwives’ perceptions of quality postnatal care 

In the focus groups, midwives were asked to discuss postnatal care. Participants believed the purpose of postnatal care was to ‘assist the transition to parenthood’ and the key outcome was ‘a healthy, happy, mother and child’. In the group discussions, the midwives tended to prioritise their role in meeting women's psychosocial needs. They outlined four aims of postnatal care and these are summarised as:

Participants also described the principles of care. These included; building a trusting relationship with the woman and focusing on their individual needs. Participants felt that, to achieve individualised care, midwives need to listen to women, be flexible in their approach and provide continuity of caregiver where possible.

Participants emphasised the importance of developing a relationship with women on the postnatal ward. It was through a relationship with a woman, that a midwife can best support a woman's emotional health, her physical recovery and the health of her baby. A good relationship was required to facilitate information sharing.

Midwives emphasised that they could develop a ‘trusting’ relationship with a woman even if they had not met the woman during pregnancy and may only see a woman for a short period over two or three shifts during the postnatal period. This relationship is best achieved by ‘actively listening to women’, ‘responding appropriately’, ‘being there’, ‘just having a chat’ and having a personal style that is ‘kind and friendly’. These participants also believed women valued humour in their interactions with midwives. Participants noted that women were keen observers of the interactions that occurred between other women and midwives and women often knew which midwives they wanted caring for them.

Participants indicated that teaching priorities should be based around the different needs of individual women, ‘starting where women are at’. Each interaction or ‘teaching session’ should commence by asking women what they already know. This requires midwives to listen attentively to what women are telling them and be flexible in their approach to care, particularly in this maternity unit that cared for many women from diverse cultural backgrounds. Participants described processes of modelling infant care and facilitating skill learning in an incremental manner and at a pace that matched women's needs.

Participants reported using a range of strategies, including ‘listening’, ‘clarifying expectations’, ‘providing relevant information’ and ‘facilitating a restful environment’, to provide for the emotional and practical support needs of the woman. They recognised that these strategies should be undertaken in a manner that enabled women to make their own decisions, particularly in relation to infant feeding. Midwives talked about flexibility in their approach to breastfeeding information and support, being conscious to ask women what they knew and what they wanted. In each of the focus groups, participants discussed the pressure they perceived women experienced in relation to breastfeeding, ‘it (the pressure) comes from us, other professionals and the community’. The participants particularly highlighted the need to provide the opportunity for women to talk about their birth experience.

Participants believed that they could support women and their families through group-based education sessions, such as breastfeeding discussion. In these group sessions, midwives should facilitate what participants described as ‘normalising of experiences’, where women could learn from each other and know they were not the only ones experiencing a problem. These sessions also could provide an opportunity to link women to community support. When discussing the value of groups, midwives talked of the need to be culturally appropriate, as group activities may not suit all women.

Even in the early days after birth, participants believed women wanted to share their experiences with other women and could learn from others through observation and sharing. This peer support could be facilitated by introducing women to one other, facilitating discussion, encouraging communal meals and participation in the group sessions. Participants acknowledged that this needed to be balanced by the woman's need for privacy and may not be appropriate if women have a short postnatal stay.

While participants recognised the role they had to monitor the physical health status of women and their infants, they expressed concern at the way in which the physical postnatal check was conducted. Some referred to this as the ‘strip search’ and they argued that ‘the evidence suggests it is not necessary to conduct a thorough physical check each day and it is more important to inform woman as to what they should expect’.

There were several factors that participants suggested facilitated quality postnatal care. These included continuity of care and having a dedicated lactation support midwife. Continuity of care was highlighted, particularly by midwives who worked in the team model of care, as the optimum way to build rapport, provide information and support and particularly, to understand women's individual needs. At the time only around 20% of women in this unit were receiving continuity of care across pregnancy, birth and the postnatal period. As an alternative, midwives providing postnatal care attempted to allocate the same midwife to women on consecutive days.

Access to the lactation support midwife was considered helpful, particularly for midwifery students, as she assisted them in formulating breastfeeding plans. This dedicated role also meant that a hospital-based midwife was available most morning shifts to provide support for team midwives who left the ward for a period during the day to undertake visits in the community.

The midwives were asked to consider the factors that hinder the provision of quality postnatal care. Primarily they stressed that clerical tasks, such as the paper work associated with daily admissions and discharges, were a major barrier to providing postnatal care in the way they wanted. Time was also lost waiting for doctors to come to discharge women, as midwifery-led discharge was not an option in this maternity unit at this time. Participants also indicated that individual midwife’ attitudes and practices hindered the provision of quality postnatal care. For example, they stated that some midwives are ‘too rushed’ or ‘brash’ or ‘inflexible’ in their approach with women. Many participants believed that the overemphasis on the daily postnatal physical check limited midwives’ ability to provide emotional and practical support and education. They contrasted hospital-based postnatal care with postnatal care in the woman's home where they are uninterrupted and can spend 30–45min with one woman focusing on her needs.

Participants also noted that the increasingly complex needs of women and families meant that midwives needed to engage with other services and workers for example, drug and alcohol workers and mental health staff and that this took time and caused interruptions to the care they were providing.

Further, workplace and organisational culture impacted on how well midwives were able to provide care. They talked of the many changes in the maternity unit over a small space of time, including the introduction of new models of care. They discussed the tensions that occurred between areas within the maternity unit and they also talked about contradictions in practices, such as trying to be flexible in the care provided and at the same time having following protocols and guidelines.

3.2. Phase Two—designing strategies to improve hospital-based postnatal care 

Drawing on the published literature, the previous research on postnatal outcomes conducted in this Area Health Service,³, ⁸ and the views of midwives obtained in Phase One, key principles for quality postnatal care were identified. The midwives agreed that quality postnatal care needed to be informed by principles such as:

Strategies needed to focus on:

3.3. The key strategy—‘One-to-One time’ 

The key strategy designed by the working group focused on providing an uninterrupted period of time when a midwife would be available for one woman. The main focus of the interaction was to provide an opportunity for the woman to be listened to and for midwives to explore and discuss issues that were important to her. Within this interaction, midwives were encouraged to discuss the physical health and recovery needs of the woman and her baby in the first few weeks after birth. Midwives were required to arrange a time with each woman that they were caring for that would allow 20–30min of uninterrupted time to discuss whatever issues the woman felt she needed. The issues could vary from a need to talk about the birth, to addressing physical changes postpartum, breastfeeding and baby care. The main aim was to provide a time that was relaxed and relational, where women could be encouraged to lead the conversation, focusing on what was relevant to them. It was also an opportunity for the midwives to be a resource for the women.

All women were to be informed about the normal physiological changes that they should expect through discussions with the midwife and by the use of an information brochure. The routine physical examination of postpartum women was to be conducted when the woman's condition necessitated it¹⁶ and incorporated into ‘One-to-One time’.

Other strategies were required to reduce the clerical tasks and to manage the other issues that interrupted time with an individual woman, such as, phone calls and requests from other women. The ward clerk was to take responsibility for entering discharge information into the computer on the afternoon before the women's planned discharge. This was to be completed by the midwife on the day of discharge. Previously the midwives were expected to complete all aspects of the computer-based discharge summary.

To enable uninterrupted time with each woman by the primary midwife, a Parenting Room was established as a resource for both women and midwives. It provided a place and a midwife (available Monday to Friday from 8 a.m. to 1 p.m.) for women to access when their primary midwife was with another woman. The Parenting Room was also the place where a scheduled group discussion was held each morning. The midwife staffing the Parenting Room would also assist in facilitating anticipatory guidance for baby care and more consistent advice on breastfeeding and other parenting issues of concern to parents. It was hoped the Parenting Room would provide peer support around parenting through the discussion of challenges common to many new mothers. Because of lack of space in the ward, the Parenting Room was also used as a place where women could have their meals together. The room was located at one end of the postnatal unit and was next to kitchen facilities.

Several strategies were put in place to increase women's opportunity for rest. With support from Delivery Suite staff, all women underwent a physical assessment prior to transfer to the postnatal unit. This minimised the need to disturb women when they first arrived on the postnatal unit. Midwives provided women with a basic orientation to the facilities, gave assistance if needed and then left women to rest. To promote a restful environment, the ward lights were kept low until 9 a.m. each morning instead of going on when the day staff arrived at 7 a.m. The afternoon rest period was also increased by 1h (12.30 to 3 p.m.). A ‘24h breakfast’ facility was available, ensuring women had the opportunity to have a light breakfast when they chose. Ancillary staff were requested to undertake activities (e.g. cleaning) in women's rooms after 9 a.m.

3.4. Training and support for midwives 

Once the key strategies were determined, a brief education program for postnatal staff was implemented. A series of five in-service sessions, each of 1-h duration, were conducted to ensure that the midwives working in the postnatal unit had the skills and confidence to implement the strategies. These sessions were repeated twice to ensure all staff had an opportunity to participate and included: a discussion of the purpose of postnatal care, communication skills to enhance skills in listening and responding to women's individual needs, facilitating group discussions, re-conceptualising the postnatal check, and a presentation and discussion session on the key elements of the strategy – ‘One-to-One time’.

A 1-month pilot phase was conducted. This allowed for clarification of the strategies and to discuss and resolve any issues that arose in providing ‘One to One Time’.

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4. Discussion 

The purpose of this study was to design, implement and evaluate strategies to improve the quality of hospital-based postnatal care. This paper presents the findings of the first two phases of the action research study and describes midwives’ perceptions of quality postnatal care and the strategies developed by midwives to improve care.

Midwives who participated in the discussion groups and interviews believed that quality postnatal care should prioritise women's needs for emotional support, rest, and information and practical assistance with infant care particularly, infant feeding. Assessment of physical health was considered necessary, but not singled out as the main focus of care. This is congruent with recent research about postnatal care that confirms women want support with their own health and adjustment to parenting, and information to assist their understanding about their infant's behaviour, health, and care.³, ¹⁷, ¹⁸, ¹⁹, ²⁰ In the immediate post-birth period, rest, reassurance, and help with infant feeding are priorities for women.⁴, ¹², ¹⁸, ²¹ Research from the United Kingdom⁴ and Australia⁵, ¹² suggest the most important aspect of postnatal care is having a midwife sit and listen to women's needs and concerns. Women want to have a trusting relationship with the midwives caring for them, receive individualised care and have midwives who are clinically competent.²², ²³

Early research that compared the priorities of new mothers and health professionals identified a mismatch in perspectives²⁴, ²⁵ with midwives and nurses tending to prioritise physical care needs while mothers were more concerned with their social and emotional needs.⁴, ⁵, ¹², ²⁶, ²⁷ The views’ of midwives in this study suggests there is now increasing congruence between women and midwives’ perceptions of what is important in postnatal care.

Attempts to meet women's needs in the immediate postnatal period have largely focused on providing continuity of care⁶, ⁷ and community-based midwifery care (early discharge programs in Australia). The option of flexible length of hospital stay continues to be received positively by women, particularly when midwifery support is available in the community.⁵, ²⁸ One study has reported the reorganisation of postnatal care through the development of a Family Suite which functioned as a self-contained apartment with a registered nurse who was available during the day to offer support with breastfeeding, baby care and educational issues.¹³

Overall, there has been little attention to developing a more individualised approach to hospital-based postnatal care. While care pathways or plans are in regular use in most hospitals, these frequently amount to a checklist of tasks and there is limited evidence that such pathways improve the quality of care.²⁹ Few studies have attempted to understand what components of postnatal care women find most helpful and there is a dearth of studies investigating innovation in postnatal care.⁵

In Phase Two of the study, midwives participated in an action research process to design strategies to improve care. The key strategy was to provide women with an uninterrupted time each day, where the midwife caring for the woman could sit and listen to her needs and concerns. This strategy was informed by research findings about women's perceptions of care (including a study conducted in the research hospital) which indicated numerous negative aspects of postnatal care provided in hospitals including: lack of rest; lack of consistent advice; the perception that midwives were too busy; inadequate time available to ask questions; inappropriate or non-individualised advice; too much information provided in a short period; and the brief and fragmented nature of midwifery care.⁸ An observational study of postnatal care in the research hospital³⁰ found there was a lack of undisturbed one-to-one contact between midwives and women in hospital. Most contact with midwives was for less than 5min, compared to between 40 and 60min when the same care was delivered by midwives at home. On average, women receive 1.5h of midwife time in a 24h period in hospital. Similarly, McKellar¹² found midwives spent only three out of 72h providing education and support. The key strategy of ‘one-to-one time’ was developed in an effort to address these concerns.

This strategy was to be supported by access to the Parenting Room and changes to ward routine including the time that the lights went on in the morning and the availability of breakfast when the women were ready. Participants recognised however, that these changes could be difficult to implement. Hospital routines are designed for acute service provision and are often not conducive to the care of healthy postnatal women, or even women who have had a caesarean birth.³¹

It is recognised that none of the strategies proposed by the participating midwives were unique or particularly different from what could be considered to be quality postnatal midwifery care. Nonetheless, the findings from phase one and two of this study highlight the need for midwives to reflect on what is often ‘taken for granted’ in postnatal care and to recognise and act on the tensions between institutional priorities to complete tasks and women's need to have a midwife take the time to listen to and address their individual concerns. The study provided a number of useful lessons for the midwives and managers on the postnatal ward about strategies that have the potential to facilitate an improved postnatal service.

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5. Conclusion 

A consistent theme in the literature is that women want sensitive caregivers to spend time with them, to understand and act on their needs, to discuss their health and recovery, and the baby's health and care needs.² The findings from Phases One and Two of this Action Research study indicate that midwives recognise the needs of postnatal women and that as a group they have the vision to rethink traditional practice and to develop strategies that have the potential to change the way in which hospital-based postnatal care is delivered. Action Research is a useful approach to engaging midwives in developing strategies for change.

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Acknowledgements 

This study was supported by funding from the NSW Health Department. We would like to thank Purdey Wong and Kathryn Henry who worked in the Centre for Midwifery, Child and Family Health in the Faculty of Nursing, Midwifery and Health at the University of Technology, Sydney at the time this project was undertaken and provided valuable research assistance.

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