Western Australian women's perceptions of the style and quality of midwifery postnatal care in hospital and at home

Article Outline

• Summary
• Introduction
• Aim
• Method
  • Sample, recruitment and data collection
  • Questionnaire
  • Data analysis
• Ethical considerations
• Results
  • Participant characteristics
  • Overall satisfaction with postnatal care
  • The style of midwifery postnatal care
    • In hospital
    • At home
    • Comparing hospital and home
  • Quality of postnatal midwifery care
    • In hospital
    • At home
    • Comparing hospital and home
• Discussion
  • The prescriptive nature of advice in chaotic hospital postnatal environments
  • Midwives focus: the short-term needs of postnatal women
  • Hospital versus home
• Conclusion
• References
• Copyright

Summary 

Aim and background

An important part of maternity service provision is the care provided by midwives in the immediate postpartum period. Evidence suggests that postpartum morbidity and its impact on women's health after childbirth is an area of genuine concern. In Western Australia there is limited information on women's postpartum health needs and/or the quality of midwifery care provided in hospital and at home. This paper describes Western Australian (WA) women's perceptions of midwifery care in the early postpartum period.

Method

A cross-sectional, self report survey was used to describe the practical, emotional and informational support provided by midwives in the initial postpartum period. A questionnaire, specially designed for this population, was posted at 8 weeks postpartum to every woman with a registered live birth in WA between February and June 2006. Completed questionnaires were received from 2699 women. Data were analysed using descriptive statistics, t-tests and chi-squared.

Results

Results indicate that overall, women were happy with most aspects of midwifery care related to practical advice and assistance in relation to baby care and their immediate physical recovery. Areas that received a less positive rating were related to providing consistent advice, availability of the midwife, emotional care and information on maternal health needs, immunisation and contraception. In general, first time mothers rated both the style and quality of care more negatively than multiparous women. There was a trend by women accessing private hospital care to rank their care less favourably. There were minimal differences noted between women in metropolitan and non-metropolitan areas. Midwifery care at home was rated very positively and significantly better than hospital care (p≤0.002).

Conclusion

Although the majority of women in this study were satisfied with the components of physical care and information and assistance with infant feeding and sleep and settling provided in the short-term, there was less satisfaction with emotional care and preparation for life at home with a new baby. This study adds to our understandings of women's experiences of the early postnatal period and provides information on which to base improvements in postnatal care and maternity services in WA and across Australia.

Keywords: Midwifery care, Postnatal period, Consistent advice, Emotional care, Models of care, Primiparous, Multiparous

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Introduction 

More than 286,000 Australian women give birth annually¹ with approximately 10% (26,538) of these births occurring in Western Australia.² A large and important part of maternity service provision is the care delivered by midwives to women and their families in the immediate postpartum period. Historically, the importance of providing quality services during the early postpartum period has gone unrecognised, been under resourced and rated as a low priority with respect to other aspects of maternity care.³, ⁴, ⁵ This has contributed to a situation where the needs of postnatal women have remained relatively invisible.⁶ As a result, current postnatal care often fails to address women's postpartum health needs, leaves many feeling dissatisfied with their maternity care, and potentially puts women at risk of suffering long term chronic health problems.⁷, ⁸

Over the last decade there has been an increasing effort, both nationally and internationally, to address the discrepancies between the delivery of health care and client needs.⁹ Initially this has taken the form of large-scale prevalence studies, which have provided a better understanding of what is happening to women and their families during this time. In the Australian state of Victoria, for example, this information has been used to inform policy, practice and organisational change.¹⁰ In New South Wales (NSW) researchers have investigated the style, content and quality of early postnatal midwifery care. Cooke and Stacey¹¹ reported that all primiparous women and two thirds of the multiparous women in their study (n=365) wanted practical assistance with, and information about, infant feeding, practical assistance with baby care and handling and settling. On assessing the quality of care provided by midwives, however, Cooke and Stacey¹¹ demonstrated that many women perceived they did not receive the information required. These findings support the earlier South Australian (SA) work of Stamp and Crowther,¹² who similarly identified the most helpful midwifery behaviours as; provision of information, assistance with breastfeeding and baby care, physical care and emotional care. Those behaviours least helpful were; conflicting advice, exclusion from decisions and inadequate support for physical care.

Emotional care has also been identified as an essential component of quality postnatal care.¹³, ¹⁴, ¹⁵ Recent work on women's psychological wellbeing, however, has been critical of midwives ability to provide postpartum emotional care. An Australian study undertaken in Queensland (QLD), with a large representative sample of women (n=592)¹⁶ identified a lack of emotional care by midwives. Similarly Yelland et al., who surveyed maternity units in Victoria, Australia, found that the psychosocial health of women was inconsistently assessed and argue that midwives need further skill development in providing psychosocial care.¹⁷ With the prevalence of health problems after birth well documented and women generally reporting they are less satisfied with postnatal care than other aspects of maternity care, some researchers have designed and trialled initiatives to improve in-hospital care and report varying levels of success.⁵, ¹⁸, ¹⁹

In the past Bick et al.⁷ argued that the limited research into care given by midwives during the postnatal period resulted in a situation where guidance for midwives is limited. More recently we have seen the development of the NICE guidelines for postnatal care.²⁰ Despite these evidence-based guidelines and knowledge of what women find supportive¹⁵, ¹⁸, ²¹ postnatal care continues to reflect great diversity with many of the routine clinical practices being rigidly adhered to despite little scientific evidence to support their benefit.²² The result of such care, as Hunter and Larrabee²³ suggested some years ago, is an inability to provide care tailored to women's individual needs and preferences.

Unlike other Australian states, there has been no large-scale prevalence study describing Western Australia (WA) women's postnatal health needs and/or their perceptions of midwifery care (style, type and content of the care). This study was conducted with a view to determining the needs of the WA population of birthing women and to inform the development of appropriate models of postnatal care.

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Aim 

This study aimed to describe WA women's postpartum health needs and perceptions of midwifery care in the early postpartum period. The specific objectives of the study presented in this paper were to;

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Method 

A cross-sectional self report survey was used to describe the perceived practical, emotional and informational support provided to women by midwives in the early postpartum period. This research in part replicated a study undertaken in NSW¹¹ in 1999; however this study was conducted with a much larger sample and included women who accessed private hospital care and those who birthed in regional/rural areas of WA.

Sample, recruitment and data collection 

Postpartum women were recruited via WA's Midwives Notification System (MNS) between February and July 2006. This is a state-wide data base that records all births in WA. Information packages, which included a letter of invitation from the Heath Department on behalf of the researchers, an information sheet, questionnaire and self-addressed prepaid envelope, were delivered to the managers of the MNS at the Health Department. Each week a list of women who had birthed was retrieved from the data base, the invitation letter individualised and the packages addressed. The packages were posted to women 8 weeks after the birth of their baby from the Health Department. Questionnaires were returned to the Health Department where they were picked up by the research team. Women were excluded if they were under 16 years of age, experienced a perinatal death and/or their baby required an extended admission to the neonatal nursery (more than 7 days). In the year preceding data collection, 26,538 births were recorded in WA.² Sampling 10% of this population was considered appropriate given the potential large number of respondents.²⁴

Initially all women were sent a reminder notice 2 weeks after the initial post out. This procedure was ceased after a month as it was a time consuming and costly strategy that did not increase the return rate.

Questionnaire 

The questionnaire was specifically developed and tested for use with postpartum women in New South Wales.¹¹ For this study, the questionnaire was modified slightly to ensure it was applicable for the WA context and to accommodate questions identifying place of birth. Section one of the questionnaire obtained demographic information (for example age of baby, marital status, level of education, mode of birth). Women were also asked to rate their overall satisfaction with postnatal care. Section two asked women to rate, using a Likert scale, the style and quality of midwifery care. Style of care, referred to the midwife's ability to share information, their demeanour and approach during interactions and their perceived availability. For example ‘were approachable and friendly’ and ‘were easy to contact and came when I needed them’. Questions pertaining to type and quality care referred to such things as information, advice and assistance with breastfeeding, sleeping and settling, contraception, and immunisation (all care components/items appear in the results Table 2, Table 3). If women accessed home visiting midwifery postnatal care they were asked the same questions in relation to these services. Section three asked questions on infant feeding patterns, visits to the child health nurse, health problems, quality of information received and types of service accessed during the early postnatal period (the analysis of these data will be the focus of separate publications).

Data analysis 

Data were analysed using the computer statistical package SPSS version 14. Prior to analysis, all variables were checked for data file errors. Simple descriptive statistics were used to summarise and describe the sample. Frequency distributions were utilised as a means of organising and presenting the data. Chi-square and independent t-tests were used to determine the differences in the postnatal needs of primiparous and multiparous women, those attending private and public health services and women in regional/rural as opposed to metropolitan areas of Perth, WA. Wilcoxon Signed Rank test was used to compare the style and quality of care in hospital and at home. An alpha of 0.05 was used to determine statistical significance.

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Ethical considerations 

Ethical approval to conduct this study was granted by the University's Human Research Ethics Committee. Following this an application was made to the Health Department's ‘Confidentiality of Health Information Committee’ for approval to access the MNS; which was subsequently granted. The study packages were posted to women from the health department. Consent was implied if a woman completed and returned the questionnaire. The questionnaires, coded for tracking purposes only, were not linked to personal details.

At the end of the questionnaire there was a section that enabled a woman to identity if she would like to discuss any of the information on the questionnaire with a researcher. Four women completed this section. They received a telephone call and were directed, when appropriate, to relevant resources.

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Results 

Participant characteristics 

Study packages were sent to 5538 women during the study period. Two thousand, six hundred and sixty nine women completed and returned a valid questionnaire (response rate of 48.2%). The majority of questionnaires were completed when the baby was 9 weeks old. Nearly 68% of participants were aged between 26 and 35 years. Thirty-eight percent of women stated that they had a degree or postgraduate qualification. Approximately 41% of women indicated they had annual income of between $40,000 and $60,000. Another 30% stated that their income was over $80,000 which was above the average full-time adult ordinary income in WA at the time of the study (AUS $58,874). Sixty-two percent stated they had private health insurance with 43% giving birth in a private hospitals. In 2004–2005 51% of Australian citizens had private health insurance.²⁵ Eighty-three percent gave birth in the metropolitan area.

Forty-four percent were first time mothers. Fifty-one percent of women had a spontaneous vaginal birth, 14.2% had an assisted birth and 34.4% had caesarean section. One thousand and fifty-six women identified that they had received postnatal care at home. In comparison to the total number of WA women who gave birth in 2006, the sample of women participating in this study were more likely to be older, to have given birth in the metropolitan area, to have accessed private hospital care and to have experienced an elective caesarean section (see Table 1).

Table 1. Participant details.

	Study women, N=2669		2006 perinatal statistics, N=28,354
	No	%	%
Mothers age
16–20	82	3.1	5.4
21–25	325	12.2	16.4
26–30	796	29.8	26.3
31–35	991	37.1	31.5
36–40	417	15.6	17.3
41–45	58	2.2	3.0
Over 45	0	0	0.1
Total	2669	100.0
Marital status
Married/defacto	2544	95.3	91.4
Single, not living with partner	101	3.8	7.2
Divorced/separated/widowed	24	0.9	1.4
Total	2669	100.0
Education status
Less than year 12	534	20.0	–
Year 12	567	21.0	–
Apprec/diploma	536	20.0	–
Degree/postgraduate	1026	38.8	–
Missing	5	0.2
Total	2663	100.0	–
Income
<$20,000	117	4.4	–
$20,001–$40,000	340	12.9	–
$40,001–$60,000	579	21.9	–
$60,001–$80,000	522	19.8	–
>$80,001	806	30.5	–
Missing	276	10.5	–
Total	2640	100.0	–
Private health insurance
Yes	1647	62.4	–
Country of birth
Australia/NZ	2106	78.9	77.7
Other	563	21.1	22.3
Total	2669	100.0	100
Parity
Primiparous	1185	44.4	41.8
Place of birth
Public hospital	1504	56.5	60.1
Private hospital	1153	43.0	38.9
Home/BBA	12	5.2	1.0
Total	2669	100	100
Health region
Metropolitan	2217	83.0	75.0
Non-Metropolitan	452	17.0	24.8
Other	0	0	0.2
Total	2669	100	100
Mode of birth
Spontaneous vaginal birth	1368	51.2	54.4
Assisted vaginal birth	377	14.2	12.8
CS	919	34.5	32.7
Breech manoeuvre	–	–	0.3
Missing	5	0.1	–
Total	2669	100	100
Received postnatal care at home
Public	1007	67.4	–
Private	249	21.7	–
Rural	224	49.9	–
Metro	1032	47.1	–

Overall satisfaction with postnatal care 

Nearly 78% women identified that they were happy or very happy with the overall postnatal care they received from midwives in hospital. Of the remaining women, 15.7% stated they had mixed feelings, 2.1% were unhappy and 4.6% were very unhappy with their postnatal care experience. There were no differences in women's overall satisfaction with care when examined by parity, pace of birth (private or public hospital) or hospital location (metropolitan or non-metropolitan).

The style of midwifery postnatal care 

Overall women rated the style of midwifery care they received in hospital very positively with 75–80% using ‘often’ or ‘always’ when responding to the different aspects of care they experienced. On average, less than 5% of women used the ‘never/seldom’ rating with approximately 20% using the ‘sometimes’ rating. Of the nine items related to style of care, there were three aspects of care that women were less satisfied with. Over 40% of women rated item C ‘provided consistent information’ as sometimes or seldom/never provided, 35% chose these ranking for item F ‘had time to listen’ and 26% rated item l ‘were easy to contact and came when needed’ as sometimes or seldom/never (Table 2).

Table 2. Style of midwifery care in home and hospital.

For some aspects of care, women's response was associated with parity and place of birth. When analysed by parity, there was a significant difference in four of the nine aspects of care with primiparous women rating the following items less favourably than multiparous women: item C ‘provided consistent information’ (p<0.000), item E ‘being approachable and friendly (p<0.025), item G ‘enabling women to feel confident’ (p<0.000) and item H ‘facilitating an active say’ (p<0.007). When data were analysed by place of birth (public/private hospital) there was a significant difference in two items; item C ‘provided consistent information’ (p<0.000) and item F ‘time to listen’ (p<0.021). Women in the private sector rated these items less favourably than those accessing public care. No differences were noted between women giving birth in rural/regional centres compared to those in the metropolitan area of Perth.

The style of midwifery care in the home environment was rated highly by those women that had access to home visiting midwifery services (Table 2). For seven of the nine aspects of care, over 88% of women choose the often-always response. There were no differences noted between (primiparous and multiparous women or when analysed by geographical location metropolitan v non metropolitan). However, when analysed by place of birth, public versus private hospital, there was a significant difference in rating of two aspects of care; item A ‘provided me with information and advice that was easy to understand’ (p<0.002) and item H ‘offered me an active say in the treatment they provided’ (p<0.003). Women accessing private hospital care scored these items less favourably, with almost double selecting the seldom or never response.

When comparing home based postnatal care with hospital based care women consistently rated the style of midwifery care they received at home more positively than that received in hospital. There was a significant difference (p<0.001) on all aspects of care [Table 2 (−18.274≤Z≤−5.882, p≤0.000)].

Quality of postnatal midwifery care 

Women were asked to rate the quality of the midwifery care they received both in hospital and at home. For the purpose of analysis the responses to items were re-categorized (and recoded) into ‘very poor/poor’, ‘adequate’ and ‘very well/excellent’ (Table 3).

Table 3. Quality of midwifery care in hospital and home.

Overall the three items rated most positively by all women (>87%) were item B ‘information on breastfeeding’, item A ‘assistance with breastfeeding’ and item N ‘supported woman's decisions about care of baby and self’. The three aspects of care that women were least satisfied with were item G ‘information received about birth control’, item J ‘information about how to identify health problems for themselves’ and item M ‘help to express their feelings about the birth’.

Multiparous and primiparous women rated six of the 17 quality care items similarly [information about infant feeding (B) and birth control (G), practical assistance with baby care (C), assistance with rest (L), and help with expressing feeling about birth (M) and parenting (P)]. There was a significant difference in ratings for the other 11 items. For all of these items multiparous women ranked the quality of care more positively than primiparous (p<0.002); particularly item E ‘information about infant immunization’ and item O ‘recognition and giving support of parenting skills’

There was a significant difference in the quality rating in five aspects of care between women accessing public and private hospital care (p<0.002). Information about infant feeding (B), immunization (E), early childhood and community resources (F) and birth control (G) were all rated less favourably by women in the private hospital sector. The reverse was true for item L ‘time to rest’. There were no significant differences between women in metropolitan and regional/rural hospitals.

For women who had postnatal care at home (n=1256) more than 80% of the women used the response ‘well/excellent’ to describe all aspects of care. The three items rated most positively by greater than 92% of the sample were item B ‘information about breastfeeding,’ item N ‘supported decisions’ and item O ‘recognition of ability as a parent and giving confidence in parenting skills’. Only item G ‘provision of information about birth control’ was rated as ‘well/excellent’ by less than 80% (78.1%). As in hospital item G ‘information about birth control’, item M ‘help to express feelings about the birth’, and item C ‘practical assistance with baby care’ appeared in the lowest ranked items.

Again multiparous women rated the quality of care provided by midwives at home more positively than primparous women (nine of the 15 items p≤0.002). There was no significant difference found between women accessing public and private hospital care for any of the items other than item G ‘information given regarding birth control’. There were no significant differences noted when data were analysed by hospital geographical location (metropolitan and non metropolitan).

When comparing how women perceived the quality of care they received at home to the care provided in hospital, there were significant differences found on all items (−12.793≤Z≤−2.644, p≤0.008) (see Table 3). Generally, women perceived the quality of their care to be better provided at home than in hospital. This was the case for all items except for item C, ‘pertaining to practical assistance with baby care’, which women on average perceived to be marginally better provided in hospital than at home.

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Discussion 

This paper reports findings from a cross-sectional, descriptive study that used self report surveys to describe Western Australian women's perception of midwifery care in the early postpartum period. Overall women rated their care positively. There were however approximately 20–25% of women who chose to respond using a mixed and/or poor rating for some items of care. These findings are similar to those elicited from a Victorian survey where approximately 18% (n=1616) of participants used a poor or mixed rating response.⁴ In line with other studies the findings highlighted the chaotic environment of hospital postnatal care where women regularly perceive the advice they receive as inconsistent and prescriptive. Similarly the evidence suggests that midwives prioritised the physical short term requirements of women and their babies over emotional components of care and information on long term health needs. Midwifery care provided at home rated highly however less than 50% of women experienced this type of care.

Although a large number of women participated in the study and 48% is a reasonable response rate (lower however than the Victorian survey which had a 67% response rate [4]) the study's population were on average older, more highly educated and had yearly incomes above the national average compared with the population of women giving birth WA at the time. Further, non-English speaking and adolescent women were under represented in the sample. The findings should therefore be interpreted within the context of these limitations. Having said this the results gained from such a large data set do provide valuable insight into the nature of postnatal care in Western Australian as well as contributing to the debate on how we might design and implement models of postnatal care that better meet women's individual needs during their transition to motherhood.

The prescriptive nature of advice in chaotic hospital postnatal environments 

Overall women were positive about the way in which midwives provided care (style of midwifery care) however, as is commonly reported in the literature (see for example 12, 26–28), women in this WA study indicated that they received inconsistent midwifery advice. This was accompanied by the finding that a high proportion of women found midwives did not have ‘time to listen’ and that sometimes they found midwives difficult ‘to contact’. These concerns remain a common feature of maternity care provided in busy and often chaotic hospital environments. For example, McKellar et al.⁵ in South Australian reported that nearly 35% of women identified that the midwives in the postnatal period appeared too busy; nearly 25% stated they were hardly available; and 15% identified their availability was interrupted. In a Victorian survey⁴ the percentages were higher with 49% of women perceiving midwives to be rushed and too busy to spend time with them. Similarly, in a Canadian study,²⁹ 43.3% of women felt that midwives were rushed in the postnatal period.

We argue that inconsistent advice is probably closely related to the lack of time that midwives have available to meet women's needs. When a midwife either does not listen or does not have time to listen she/he misses the opportunity to ask the woman what she may or may not know and what she would like help with. This limits the ability of the midwife to make an adequate assessment and provide care that is tailored to woman's individual needs; another common area of dissatisfaction with hospital postnatal care.⁹, ³⁰, ³¹ In addition, while we acknowledge that some midwives do in fact provide different advice we also suggest that it is likely some midwives provide similar advice however different people, ‘couch’ or share advice/information in different ways. Without adequate time to discuss the information with the midwife, the woman is left to sift through and discern for herself what is most appropriate. A lack of time on the midwives part also means that there is a tendency to deliver information in a ‘black and white’ or prescriptive manner. This is reinforced and perpetuated by an organisational ‘tick box’ approach to care, which tends to emphasis a list of ‘tasks’ to get through and ‘one right way to do things’.³², ³³ Dykes highlights this in her UK study of breastfeeding in hospital where she uses the metaphor of the production line to describe the postnatal environment and women's experience of ‘supply’ and ‘demand’ learning to breastfeed in the institutional context.³⁴ The crucial point here to acknowledge is that where midwifery continuity of carer is a characteristic of postnatal care women are much less likely to identify inconsistent advice as a feature of their postnatal experience and more likely to describe their postnatal care as meeting their needs and expectations.³⁵

Women having their first baby described the style of midwifery care they received more negatively than did women who were having a subsequent baby. Interestingly however, less than 50% of multiparous women used ‘always’ to respond to the aspect of care related to providing women with reassurance. We suggest, as did Cooke and Stacey,¹¹ that this may be related to midwives assumption that women having a second and subsequent baby do not need as much help, support and/or reassurance. Often there is little consideration of the woman's previous experience, which may in fact have been traumatic or distressing (for example major breastfeeding problems). This is again likely to be influenced by the chaotic nature of postnatal care that forces midwives to prioritise their workload based on their own needs of caring for a group of women and their babies, rather than the individual women who all have individual circumstances and different past experiences.³² Certainly the work of McKellar et al.⁵ bears this assumption out with nearly double the number of multiparous women (22.3% versus 12% first time mothers) stating that midwives appeared too busy. This was accompanied by a significant difference in the number of multiparous women who also identified that when they did see a midwife they were regularly interrupted (11.1% versus 4% first time mothers).

Midwives focus: the short-term needs of postnatal women 

In terms of the quality of midwifery care, on average some 10% of women used the ‘poor’ or ‘very poor’ rating, a further 20–30% used ‘adequate’ and between 60–70% used ‘well or excellent’. Care that related to the short-term practical aspects of postnatal care, such as information and practical assistance with breastfeeding rated highly. As Cooke and Stacey¹¹ suggest this is likely to be the result of midwives continued priority on teaching women how to care for their baby in the immediate postnatal period.

Aspects of care related to the provision of information and support on issues pertaining to the long-term health needs of women were less likely to be received and/or rated less well. This finding continues to support previous work that suggests women's own physical needs are not being met.¹¹, ³⁶, ³⁷, ³⁸ These findings are almost certainly the result of a continued focus on acute hospital based care for childbearing women. This model undervalues postnatal care and perpetuates poor referral pathways between hospital and community-based care.²⁸ It has also resulted in a situation where very few Australian midwives have worked outside the hospital setting and/or have provided postnatal care for longer than 7 days. As a consequence, midwives often lack an understanding of what the early weeks of mothering might be like and therefore what information and resources might best help an individual woman (and her partner) adapt and adjust to the early parenting period. While women have identified that they need to spend more time with midwives to be prepared for life at home²⁸, ³¹ we echo McKellar et al.⁵ call that the midwife's role as a key educational provider must be more fully developed.

Similarly, this situation has implications for providing emotional care. Overall a higher percentage of women rated midwives ability to help women express their feelings as poor. This is consistent with the literature.¹³, ²⁷, ³⁶ For example an Australian study undertaken in Queensland (QLD), with a large representative sample of women (n=592)¹⁶ identified a lack of emotional care by midwives. Although the majority of women in this study were highly satisfied with the technical components of care, there was less satisfaction with the emotional aspects of care. Often staff did not ask women how they felt about the birth, with only 13.5% of participants reporting that this occurred. Only half of the sample (49%) felt that staff encouraged questions about the birth, with fewer than half reporting they were satisfied with staff communication. These findings were confirmed by Gamble³⁹ and later by Cooke and Stacey.¹¹ The percentages obtained in this current study however were much less than those identified in Cooke and Stacey's¹¹ work which this study replicated. This maybe the result of women recognising that the midwife is time poor and lowering their expectations of receiving care that is not directly related to immediate practical needs. Having said this, recently Yelland et al.¹⁷ identified that the level of psychosocial health assessment provided by midwives in the early postnatal period remains inconsistent and affected by the hectic nature of the postnatal ward. The analysis of the 38 key participant interviews, from 14 public Victorian facilities, also revealed that the postpartum emotional health of women was often considered the domain of antenatal providers and social workers. More concerning was the finding that a number of respondents considered there to be no specific requirements to undertake assessment of emotional wellbeing in the early postnatal period.

A surprising finding of this study was that women accessing private hospital care scored a number of items, related to the quality of midwifery care, less favourably than women in the public system. This might be explained by the ideology of consumerism whereby there is an expectation that if you ‘pay’ for a service you have a right to be more critical of it. It may also be related to the fact that nearly 76% of women reported receiving care from between 8 and 16 different midwives during their stay. These findings contrast with those reported in WA in 1995,²⁶ when little difference between women in the public and private sectors was noted, except women without private health cover were more concerned with receiving care as opposed to privately insured women who reported being more concerned about staff and informational needs. The findings are also different to those reported in Victoria where women in private models of care were significantly more likely to rate aspects of postnatal care more positively.⁴

Hospital versus home 

Women who received home based midwifery care consistently rated both the style and quality of care more highly than hospital based postnatal care. While on average, women perceived the quality of the care they received in hospital to fall within the ‘adequate’ to ‘well’ range, on average aspects of care delivery at home fell within the ‘well’ to ‘excellent’ range. This supports the available evidence that women who receive home visiting in the postnatal period are more satisfied with the care received.⁴⁰, ⁴¹, ⁴², ⁴³, ⁴⁴ However, only 50% of the participants in the study identified that they had received any postnatal home midwifery visits. A continued focus on providing antenatal and intrapartum care in hospital whilst simultaneously trying to reduce women's length of postnatal stay, without providing community support, is inappropriate, outdated and unsustainable. Although there remains some debate as to whether universal postnatal support to low risk mothers improves outcomes⁴⁵ we argue that further research needs to address how postnatal care can be reorganised to incorporate the principles of primary health care and continuity of carer.

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Conclusion 

The findings presented in this study continue to demonstrate that postnatal care remains problematic. While in general terms women perceived midwives to be friendly, approachable and encouraging in the hospital postnatal period they simultaneously identity them to be busy, rushed and difficult to contact. As a result, midwives did not appear to have the time to deliver consistent information and advice pertaining to a woman's individualised needs. Similarly, aspects of quality care such as assistance and information pertaining to feeding and the immediate needs of infants were rated very positively as opposed to care focused on the women's emotional wellbeing and her longer-term health needs. To provide effective care to new mothers and their infants during the initial postnatal period, it is clear that midwives need to not only better understand the health problems facing women following childbirth, but that they need to develop specific skills that will improve long term maternal and family physical and emotional outcomes.

While less than 50% of women in this study reported having midwifery postnatal care at home the style and the quality of midwifery care in this environment was consistently rated more positively for all items than in hospital. The challenge for the midwifery profession, other health care professions and organisations is how to act upon the findings. The medicalisation of birth and motherhood, which is consistently reinforced by the routine and ritualistic nature of current maternity care, needs urgent attention. Valuing postnatal care and situating it within the continuum of the childbirth journey is essential. Policy and leadership direction is needed in this clinical area. The development and implementation of strategies and/or new models of care that value sensitive and relational interactions between women and their care providers within the framework of primary health care, is the way forward. Evaluation should take into account the physical and emotional long-term health outcomes of both women and their infants.

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References 

1. Australian Bureau of Statistics. 1301.0 Year Book Australia, 2008. Canberra, ACT: ABS.
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