Enhancing early postnatal care: findings from a major reform of maternity care in three Australian hospitals

Abstract

Background

four hospitals comprising a health network in Melbourne, Australia, implemented a range of initiatives aimed at enhancing women's experiences of postnatal maternity care.

Objective

to compare women's views and experiences of early postnatal care before and after implementation of maternity enhancement initiatives.

Design

‘before and after’ study design incorporating two postal surveys of recent mothers (baseline and post-implementation).

Setting

four hospitals in Melbourne, Australia. Analysis of postnatal outcomes was confined to three hospitals where the initiatives were fully operational.

Participants

1256 women participated in the baseline survey in 1999 (before implementing the initiative) and 1050 women responded to the post-implementation survey in 2001.

Findings

the response to the 1999 baseline survey was 65.3% (1256/1922) and to the 2001 post-implementation survey 57.4% (1050/1829). Comparative analysis revealed a statistically significant improvement in overall ratings of hospital postnatal care; the level of advice and support received in relation to discharge and going home; the sensitivity of caregivers; and the proportion of women receiving domiciliary care after discharge. There was little change in the time women spent in hospital after birth between the two survey time-points. Over 90% of women reported one or more health problems in the first 3 months postpartum. The proportion of women reporting physical or emotional health problems between the two surveys did not change.

Key conclusion

mainstream maternity care can be restructured to improve women's experiences of early postnatal care.

Implications for practice

maternity service providers should consider a multi-faceted approach to reorientating postnatal services and improving women's experiences of care. Approaches worthy of consideration include attempts to ensure consistency and continuity of care through staffing arrangements, guidelines and protocols; an emphasis on planning for postnatal care during pregnancy; the use of evidence to inform both consumer information and advice and in the practice of caring; and skill-enhancement opportunities for care providers in managing postnatal issues and in effective communication.

Introduction

About 250,000 women every year in Australia spend some time in hospital after birth. Childbirth is the most common reason for a hospital stay of at least one night. Almost 50% of women on postnatal wards are recovering from caesarean section or operative vaginal births, most women will have either an abdominal wound or perineal laceration or episiotomy, and many will be recovering from lengthy labours.

A recent review of postnatal care in the State of Victoria revealed a busy and at times chaotic environment in postnatal wards, with an increasing intensity in workloads in many maternity units (Forster et al., 2005). The increasing caesarean section rate, rise in multiple births and declining length of postnatal hospital stay result in different demands for postnatal staff than have been experienced in the past.

Women in Victoria have consistently rated postnatal care far less favourably than antenatal and intrapartum care. About half of the women participating in the 1994 Victorian Survey of Recent Mothers rated their postnatal care as ‘very good’ (Brown and Lumley, 1997b, Brown and Lumley, 1997c). When the survey was repeated in 2000, women's overall rating of hospital postnatal care had failed to improve (Bruinsma et al., 2001; Brown et al., 2002, Brown et al., 2005). Similar findings have been reported internationally (Garcia et al., 1998; McCourt et al., 1998).

These studies provided the impetus for the reforms to postnatal care at a network of four Melbourne hospitals as part of a State government-funded maternity services enhancement strategy. This maternity enhancement project focused on both the synthesis of existing evidence and the development of new evidence to improve the provision of maternity care, particularly postnatal care.

Not long after the initiatives began, one maternity facility, Sandringham Hospital, was moved out of the network's central management. This paper includes findings from the women who gave birth at the remaining three public maternity units under the health network ‘Southern Health’, including a tertiary referral service with neonatal intensive care facilities (Monash Medical Centre, Clayton campus), a maternity unit with a special care nursery (Dandenong Hospital) and one smaller unit (Monash Medical Centre, Moorabbin campus). Across the health service, over 5000 women give birth every year, including a significant number of immigrant women born in non-English-speaking countries (40.4% in 2000).

The organisation of care at Southern Health was structured around antenatal, intrapartum and postnatal care. All women were admitted to the hospital postnatal ward after birth, with the exception of women who gave birth in a midwives birth centre. The postnatal wards operated as discrete units, staffed by midwives.

The extensive set of maternity enhancement strategies (the intervention) included an emphasis on improving early postnatal care, with opportunities for women to plan for the postnatal period through discussion visits with midwives in the third trimester; the development of consumer written information focusing on the postnatal period, including maternal health, baby care and sources of support and advice after discharge; rotation of midwifery staff across intrapartum and postnatal care involving the formation of teams, creative rostering, mentoring and professional development opportunities; midwife skill-enhancement programmes, including communication skills training; the development of a hospital-based domiciliary service (‘Extended Postnatal Care’) staffed by teams of midwives on rotation from labour and postnatal wards; and the development of evidence-based guidelines and protocols (e.g. breast-feeding). The formation of midwife teams to rotate between the labour ward, postnatal wards and domiciliary care required a major restructure to the organisation of the midwifery workforce, and proved to be a major undertaking for the health service (Yelland et al., 2003c).

A 4-year evaluation of the initiatives (EPOCS: Evaluating practice and the organisation of care at Southern Health and Sandringham Hospital) involved two large postal surveys of recent mothers using a ‘before and after’ study design, process evaluation, interviews with women of non-English-speaking background, and monitoring of emergency department attendances and readmissions of women and their babies. The comparative analysis presented in this paper aimed to determine the effect of the initiatives on women's views and experiences of early postnatal care.