Women's views of postnatal care in the context of the increasing pressure on postnatal beds in Australia
Article Outline
- Summary
- 1. Introduction
- 2. Methods
- 3. Results
- 4. Discussion
- 5. Conclusion
- Acknowledgements
- References
- Copyright
Summary
Background
Despite limited evidence evaluating early postnatal discharge, length of hospital stay has declined dramatically in Australia since the 1980s. The recent rising birth rate in Victoria, Australia has increased pressure on hospital beds, and many services have responded by discharging women earlier than planned, often with little preparation during pregnancy. We aimed to explore the views of women and their partners regarding a number of theoretical postnatal care ‘packages’ that could provide an alternative approach to early postnatal care.
Methods
Eight focus groups and four interviews were held in rural and metropolitan Victoria in 2006 with participants who had experienced a mix of public and private maternity care. These included 8 pregnant women, 42 recent mothers and 2 male partners. All were fluent in English. Focus groups explored participants’ experiences and/or expectations of early postnatal care in hospital and at home and their views of alternative packages of postnatal care where location of care shifted from hospital to home and/or hotel. This paper describes the packages and explores and describes what ‘value’ women placed on the various components of care.
Findings
Overall, women expressed a preference for what they had experienced or expected, which may be explained by the ‘what is must be best’ phenomenon where women place value on the status quo. They generally did not respond favourably towards the alternative postnatal care packages, with concerns about any shorter length of hospital stay, especially for first time mothers. Women were concerned about the safety and wellbeing of their new baby and reported that they lacked confidence in their ability to care for their baby. The physical presence and availability of professional support was seen to alleviate these concerns, especially for first time mothers. Participants did not believe that increased domiciliary visits compensated for forgoing the perceived security and value of staying in hospital. Women generally valued staying in hospital for the length of time they felt they needed above all other factors.
Key conclusions and implications for practice
Women were concerned about shortened postnatal length of hospital stay and these concerns must be considered when changes are planned in maternity service provision. Any moves towards shorter postnatal length of stay must be comprehensively evaluated with consideration given to exploring consumer views and satisfaction. There is also a need for flexibility in postnatal care that acknowledges women's individual needs.
Keywords: Postnatal care, Midwifery, Organisation of care, Focus groups, Women's experiences
1. Introduction
Despite limited evidence evaluating early postnatal discharge, length of hospital stay has declined dramatically in Australia since the 1980s. Shorter hospital stays have been exacerbated by the dramatic and relatively unpredicted rise in the number of women giving birth in Australia.1 Many hospitals, especially tertiary referral centres, have needed to respond by discharging new mothers much earlier than women expected, in many instances with little or no preparation during pregnancy (personal communication, Victorian maternity managers, January 2008). The shortened length of stay and the increased number of women giving birth are factors driving postnatal care practices, rather than a systematic, evidence-based approach to ensuring optimal care of mothers and babies.
In Victoria, women stay in hospital on average three to four days following a normal vaginal birth and four to five days following a caesarean section, with marked variation by hospital category and location.2 A Cochrane systematic review concluded that while there was no evidence of adverse outcomes associated with policies of early discharge, included trials had methodological limitations, and large well-designed trials were needed.3
In a state-wide survey of recent mothers in Victoria in 2000, staying in hospital for one to two days after birth was associated with less positive ratings of postnatal care, compared with the views of women who stayed five days or more.4 The survey also reported that of the three episodes of maternity care, women are least likely to be satisfied with postnatal care, with only 50% of women rating their postnatal care as ‘very good’. In contrast, 67% and 72% rated antenatal care and intrapartum care respectively as ‘very good’. The factors most strongly associated with negative ratings of postnatal care were those reflecting women's experiences of specific aspects of care such as the sensitivity and helpfulness of caregivers.4
Until 1998, Victorian public hospitals had responsibility for the provision of postnatal care during the five days following birth.5 Since then, the boundaries for hospital responsibility are defined by clinical judgement rather than time, with hospitals required to offer a minimum of one postnatal contact following discharge.6 There is no systematic routine domiciliary postnatal care for women choosing private maternity care.
The current situation regarding postnatal accommodation in a number of Victorian hospitals has become critical. Women are being discharged earlier in a context of very limited evidence of the impact of a shortened postnatal stay on maternal or infant health. In response to these issues and on the basis of the results of a Victorian state-wide review of hospital postnatal care7 we plan to explore an alternative approach to early postnatal care.
The aim of the study reported here was to explore the views of women and their partners regarding a number of proposed postnatal care ‘packages’ that could provide an alternative approach to early postnatal care. These findings will inform the development of an intervention that can be implemented and evaluated in a randomised controlled trial. This paper reports on the findings related to the proposed packages. Participants’ views and expectations of postnatal care more generally were also explored with two global themes emerging: anxiety and/or fear around the health and wellbeing of the baby and the transition to motherhood and parenting. These findings are reported elsewhere.8
2. Methods
We used focus groups to explore participants’ views on proposed alternative ‘packages’ of postnatal care. Focus groups were used due to the potential effects of the group setting in eliciting ideas and discussion which may not have occurred in individual interviews.9
Groups were held in the catchment areas of public and private hospitals that had expressed interest in evaluating alternative postnatal care options and/or in restructuring postnatal care (two metropolitan, one regional and one rural). We planned to capture the views of a range of women including those who: were currently pregnant; had recently had their first baby; or had given birth to more than one baby. We also aimed to include some new partners. Participants needed to be fluent in English. Recruitment strategies included: distribution of flyers in pregnancy clinics; letters of invitation sent from Maternal and Child Health (MCH) centres to recent mothers in their care; and verbal invitations to women in new mothers’ groups from their MCH nurse. Written informed consent was obtained prior to the commencement of each focus group.
Ethical approval for the study was provided by the Research Ethics Committees of La Trobe University, the Department of Human Services Victoria, Mercy Hospital for Women and Barwon Health.
2.1. Data collection and analysis
Focus groups were facilitated by experienced interviewers who followed topic guides developed for the study. These guides were based on earlier research and findings from other studies.4, 7 Early questions pertained to issues around postnatal care; to explore participants’ experiences or expectations of postnatal care in hospital and at home.8 Four alternative postnatal care packages were then presented to elicit participants’ views and to prompt discussion about the value of the different attributes of care packages. Participants were invited to comment on the packages as compared to the current standard care at public hospitals (and for some women compared to the care available in the private sector).
In light of the limited research evidence on best practice postnatal care, the proposed packages were developed. The packages were based on prior meetings with public and private hospital managers regarding feasible alternatives to the current postnatal length of stay and domiciliary care arrangements, in terms of hospital budgets and logistics. Package options (detailed in Table 1) differed in length of hospital stay, number of domiciliary midwife visits, hotel care as an option and continuity of midwife care. The packages were introduced one at a time and participants were asked: what they liked and disliked about each; trade-offs they would be willing to consider; what was missing from the packages; changes they would like to make and which package they would choose.
Table 1. Proposed ‘packages’ presented to focus group participants.
| Care option | Length of hospital postnatal stay | Number of domiciliary visits | |
|---|---|---|---|
| Vaginal birth | Caesarean birth | ||
| Standard care | 2–3 nights | 4–5 nights | 1–2 visits |
| Package 1: Hospital care | 1 night | 3 nights | 3 visits |
| Package 2: Known midwife care | 1 night | 3 nights | 2 visits with a known midwife |
| Package 3: Hotel care | 1 night hospital 2 nights hotel | 2 nights hospital 2 nights hotel | 1 visit |
| Package 4: Home care | Same day | 2 nights | 4 visits |
All discussions were audio-recorded and field notes taken. Discussions were transcribed verbatim and the transcripts checked against the recording for accuracy. Names of individuals and institutions were removed to ensure confidentiality. A thematic network was constructed to describe and connect categories with emerging basic, organizing, and global themes to describe the data.10 Transcripts were read and re-read to gain an overall perspective, then a step-by-step approach used. Firstly, a coding framework was developed to reduce the text to meaningful and manageable parts, then basic themes that emerged from the text were identified; these formed the ‘lowest order’ of ideas emerging from the text. These basic themes, which on their own provide very little information about the data as a whole were then summarised into more abstract groups, called ‘organizing themes’ in order to cluster the basic themes together where they related to similar issues. Finally the organizing themes were summarised as overriding metaphors, or global themes to enable us to make sense of the clusters of lower order themes.10 Thus the global themes are a summary of the main themes, as well as our interpretation of the data from this analysis.
Analysis was conducted by two authors (SR, JR) and crosschecked by two others (DF, JY). Preliminary themes were presented to the whole team with the transcripts for further discussion and agreement. Quotes are presented with an identifier including (when known) parity, location of group, public/private status and if the woman was pregnant or had already had her baby, e.g. (primiparous, non-metropolitan, public, postnatal). Text added to quotes to enhance reader understanding is marked by square brackets, i.e. [].
3. Results
3.1. Participants
Eight focus groups and four individual interviews were conducted between August and October 2006, with a total of 52 participants. Interviews were undertaken when only one participant attended a focus group session or a participant was unable to attend but requested participation. The groups included 8 pregnant women (of whom 7 were pregnant with their first baby), 42 women who had experienced postnatal care (some had one child and some more), and 2 male partners. We recruited fewer pregnant women and fewer partners than we aimed for. This was despite trying a number of different recruitment strategies such as fliers, letters of invitation and offering to run the groups at flexible times and locations. Of the participants who were postpartum, they ranged between 6 weeks and 12 months. Seventeen participants received public care, 11 private and for the remaining 24 participants, we were unable to determine their accommodation status from either field notes or transcripts.
3.2. Global theme: individualised care
Participants did not respond particularly favourably towards any of the proposed packages. The main concern was about the shorter length of postnatal hospital stay (compared to standard care) associated with each of the alternative packages. The proposed shorter hospital stay was different from what most participants expected or had experienced. Women generally did not want care that was different to what they had received or were expecting. The global theme in relation to the proposed packages was the importance of individualised care. Participants emphasised flexibility and the importance of individualised care for women.
This is the most important thing we’ll ever do in our lives you know so you don’t want to feel like cattle (primiparous, non-metropolitan, postnatal)
Flexibility was seen as the key to providing adequate postnatal care, and this needed to be a factor that was open to last minute changes:
How do you know you’re gonna [sic] be ready to go home … I could not have gone home after a few hours, … I would have been way too frightened to do that I think, … flexibility [is important] (primiparous, non-metropolitan, public, postnatal)
The importance of individualising care was mentioned in response to most aspects of discussion.
We were interested in how the packages compared with each other; which did women favour and why—what value did they place on the various aspects? In the following sections we describe the value that women placed on the various aspects of care, and how these related to each other.
3.3. The value of the postnatal hospital stay
Many issues raised by women were discussed in terms of the length of the hospital stay and they how matched their expectations for the postnatal period.
Postnatal participants reported being concerned about medical safety in the first few days after giving birth, and many lacked confidence in their ability to care for the baby. The hospital setting was perceived to provide 24-h midwifery support, with access to immediate medical care if needed. These factors helped alleviate women's anxiety, with continuous access to midwifery support seen as essential to building maternal confidence. A postnatal hospital stay of one night (following normal delivery) was seen as inadequate, especially for first time mothers.
The level of concern expressed by participants was proportional to the reduction in length of postnatal hospital stay offered in the proposed care packages compared to standard care. Most participants expressed the greatest concern about package four (which encompassed the shortest length of stay); in particular about going home so soon after the birth of their baby.
Prefer to have longer in hospital, feel safer if anything goes badly (primiparous, metropolitan, public, postnatal)
I could not have gone home after a few hours … I would have been way too frightened to do that (multiparous, rural, public, postnatal)
If I’m in hospital I’m there because medically I need to be there or you know there are issues that are gonna come up … we do not know what it is to look for … so I myself am happy with a longer stay (primiparous, rural, public, postnatal)
3.4. Value placed on domiciliary care
Postnatal midwifery care delivered in the home, and the increased provision of such care, was generally seen to be a good option, although most women were not willing to trade this for a shorter hospital stay. One view of the ideal provision of domiciliary care associated with early discharge was:
I think [early discharge] would work for me if I could go home with the midwife, actually come in the car with us or follow us home and say ‘ok this is how you make it in your home’ …. I think the initial terror of leaving the hospital, going ‘what have I done’ or ‘why am I in my car going home, I just had a baby yesterday’ I would like that midwife to come with me and just sort of see what I’m doing at home and say ‘ok this is [what you do]’ (nulliparous, metropolitan, public, antenatal)
There were, however, some women who held negative values for care provided in their home:
… if you are not comfortable with anyone coming out to your house … you should be given the option to bring your child back to the hospital (nulliparous, non-metropolitan, antenatal)
3.5. Values related to a known midwife
Values attached to the provision of domiciliary care by a known midwife (i.e. a midwife who had cared for the woman previously), over and above values attached to the provision of domiciliary care per se, were mixed. Women appreciated the idea of continuity of care embodied in the concept of known midwife care, although the extent to which they attached positive value to having a known (as opposed to any other) midwife varied:
[I] … like the idea of continuity of care, and the continuity of information that women would be given at visits (primiparous, metropolitan, private, postnatal)
I do not think [having a known midwife] would matter … I would definitely need more than one night in hospital to feel prepared to go home, and all the midwives that we had except for one were great… (primiparous, metropolitan, private, postnatal)
Much of the discussion prompted by the proposed package of known midwife care related to the ability to choose the midwife:
Can you have a choice though? …otherwise don’t bother if it's one of the ones we don’t like…[would make] it worse, following you home as well (primiparous, metropolitan, private, postnatal)
3.6. Values for hotel care
The rationale for a package including hotel care was based on a recent move (predominantly by private hospitals) to offer hotel-based postnatal care to women who have an uncomplicated birth and a healthy infant. The option of moving from hospital to hotel as described in Package 3 was attractive to some participants, particularly due to the continued provision of 24-h midwife availability in the hotel.
I think to be in a hotel and having the safety net of still having that hospital care but … in a lot more relaxed setting similar to a home environment [sounds good] (primiparous, non-metropolitan, postnatal)
Other women saw a hotel as the least preferred location of care. This group was split into two opinion groups. The first group would prefer to be at home rather than in a hotel, and/or they did not like the idea of moving twice:
I’d hate the hotel … I’d rather just go … straight home and be surrounded by things that I’m familiar with and be able to have my mum and my sister around and … my partner … just to have…[a] kettle to make a cup of tea, I could go out to the garden … so it's not for me…(nulliparous, metropolitan, public, antenatal)
The last thing I want to do is to pack everything up and move and then have to pack everything up again and then go home (primiparous, metropolitan, private, postnatal)
The second group saw the offer of hotel care as an inadequate attempt to solve the problem of insufficient hospital accommodation. They felt that hotel care would not meet the needs of women in the early postnatal period (e.g. medical care, support) and this group preferred a longer hospital stay to any shift in location of care.
I think …it's … not fixing the problem it's just skirting the issue which is they don’t have enough space … what happens when there is not enough space in the hotels … (primiparous, metropolitan, private, postnatal)
For a final group in a rural area the local hotel was not seen as an attractive option.
4. Discussion
The participants in this study did not generally respond favourably to the proposed alternative postnatal care packages. Their major concerns related to a shorter length of stay, especially for first time mothers. The physical presence and availability of professional support was seen to alleviate these concerns. Women wanted to use their time in hospital to learn the skills they needed, and did not want to leave hospital before this was achieved. Participants did not believe that increased domiciliary visits compensated for forgoing the perceived security and value of staying in hospital.
The participants were generally of the view that there should be different care options for first time mothers compared with women who already had children. Women who had given birth to only one baby did not want to consider experiencing different postnatal care to what they had received. The findings support the increasing body of evidence that there is a need for flexibility in postnatal care options, with acknowledgement of each woman's needs, and how these may change depending on parity and prior experience.11
This study demonstrated that while women valued many of the individual aspects of the proposed packages, the trade-offs inherent in the packages compared to current or standard care were not positively received. The value attached to the hospital postnatal stay was far greater than that attached to a potential hotel stay, number of midwife home visits, or to the idea of having a known midwife providing domiciliary care. This difference in value for different aspects of care was so strong that, within the scope of the feasible options posed in this study, women were not prepared to trade an increased number of home visits for a reduced postnatal hospital stay. There was some willingness to trade hotel for hospital as the location of postnatal care, although there were clear differences between women in the relative value of the hotel versus the hospital. Therefore, while participants liked aspects of the presented packages, they would not be happy with any of the entire alternative postnatal care packages presented.
The dominant view was that women wanted a postnatal hospital length of stay similar to that recently experienced or currently expected and they were prepared to trade off almost anything else in order to maintain this length of postnatal hospital stay. These findings may be explained by the ‘what is must be best’ phenomenon where individuals value the status quo over innovations of which they have no experience and that care that is received is preferred because the actual experience of something gives it value.12, 13 The challenges in measuring satisfaction and measuring proposed alternatives to the status quo were described in the early 1980s by Porter and McIntyre who reported that “where they express a preference, it is generally for whatever arrangements they have experienced rather than for other possible arrangements”[12, p. 1197]. This is likely to have been a factor in this study where women generally expressed support for the length of stay they had experienced or expected.
Given the finding that women did not respond favourably to any of our proposed alternatives, another approach could be to explore the views of women who have experienced other models of postnatal care and to identify what factors may contribute to a more positive or negative experience. The groups might include for example, women who have given birth in a birth centre and have had more home-based postnatal care, or women who have experienced birth at home. Additionally, if alternative approaches to postnatal care are implemented by care providers, then preparation for these alternatives should be an important component of care given the level of concern expressed by women in this study.
There are both benefits and limitations of the focus group methodology. Women recruited through the maternal and child health centres were predominantly members of established new mothers group and there were likely to be group dynamics where participants were known to each other. These study findings are from a purposively selected sample and may not be generalisable to all women.
Maternal and infant clinical outcomes and the association with length of hospital stay following childbirth require further research. Satisfaction is also an outcome that policy makers nationally and internationally are increasingly considering as an indicator of quality care and women's views should be included in planning and organising maternity care.4, 14, 15, 16, 17 The recent national survey of women's experiences of maternity care in the United Kingdom concludes that health professionals and policy makers need to listen to women and to continue to ask their views of their care.18 Patient satisfaction can be used in assessing improvement in processes and outcomes19 and there may be an association between higher patient satisfaction and improved health outcomes.20 In Victoria, an association between length of stay and women's satisfaction with postnatal care has been shown.4 It may be timely to further explore this association. Given this study included fluent English-speaking women, it may also be timely to further explore the views of women from non English-speaking background regarding postnatal care. Further, despite our efforts to include more partners, further research could also explore the views of this group.
5. Conclusion
While acknowledging the challenges in asking women to reflect on care alternatives that they had not expected or experienced, women expressed concern and scepticism about moves to shorten postnatal length of hospital stay, especially for first time mothers. The participating women did not believe that increased domiciliary visits compensate for forgoing the perceived security and value of staying in hospital. It is crucial that women's concerns and needs be considered when service delivery changes are planned. Hence it is important that any moves towards shorter postnatal length of hospital stay is evaluated in terms of the physical and mental health of both mother and baby, and the parents’ satisfaction with the care received. There is also a need for flexibility in postnatal care that acknowledges women's individual needs.
Acknowledgements
We would like to acknowledge the women and men who participated in this study. Thank you to our colleagues in the community who helped facilitate recruitment and to our colleagues, in particular Stephanie Brown and Judith Lumley for their thoughtful consideration of new approaches to postnatal care. Thank you also to maternity managers Tanya Farrell (Royal Women's Hospital); Therese Cotter (Barwon Health); Donna McKendry (St John of God Hospital, Berwick) and Caroline Edwards (West Gippsland Healthcare Group) for their comments and feedback regarding the packages of care. We gratefully acknowledge (MCHR) and the Faculty of Health Sciences at La Trobe University for providing funding to undertake the project.
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PII: S1871-5192(09)00045-6
doi:10.1016/j.wombi.2009.04.003
© 2009 Australian College of Midwives. Published by Elsevier Inc. All rights reserved.
