Why We Need to Prioritise Post-natal Care


birth; however, evidence from several large observational studies published in the 1990s refuted this, as the results showed that many women experienced chronic physical and psychological health problems that persisted well beyond six to eight weeks, including backache, urinary and faecal incontinence, perineal pain, sexual problems, extreme fatigue and depression.6–8


The majority of women in the UK and other developed countries now give birth in hospital, following which they will be transferred to a post-natal ward prior to discharge home. Evidence that the traditional content and timing of post-natal care was not appropriate begged the question of why this traditional system of care persisted and whether it was possible to revise the timing and content of care to better meet women’s needs. Several randomised controlled trials compared the outcomes of revisions to aspects of routine post-natal care, although not all found benefits for maternal health. A trial in Australia compared outcomes of an early post-natal review by the family doctor at one week after birth with a post-natal review at six to eight weeks.9


Only


the timing of the consultation was altered as part of the intervention, with doctors asked not to alter the content of care (other than advising that a vaginal examination should be undertaken at one week only if medically indicated). Women recruited to the study (n=683) were followed up at three- and six-months post-birth, with results showing no significant differences in any of the major health outcomes studied (which included physical health problems, breastfeeding rates, depression and women’s satisfaction with care). The researchers concluded that, to make clinically important improvements to maternal health, more was required than early post-natal review.


Two large UK trials that assessed the outcomes of interventions provided as an addition to routine post-natal care also found no differences in maternal health outcomes. In 2000, Morrell et al.10 undertook a trial in Sheffield to examine the costs and benefits of maternity support workers on women’s health. Trained lay support workers visited women, offering up to 10 three-hour-long visits within the first 28 days of birth to provide practical and emotional support. The primary study outcome was the general health perception domain of the Short Form 36 Health Survey (SF36), a measure of general wellbeing; there were no differences in this measure at six weeks or six months post-birth or in any of the secondary outcome measures, which included the Edinburgh Post-natal Depression Score (EPDS), the Duke Functional Social Support Scale and breastfeeding rates. Women who received the intervention were more satisfied with the support workers’ input than with all other services received, although uptake of visits was low: only 15 % of the 311 women allocated to the support worker visit group received all 10 visits. In 2002, Reid and colleagues11


from Glasgow undertook a trial of


additional post-natal support in which women were invited to either attend a local post-natal support group or receive a post-natal support booklet through the post, or both. A range of physical and psychological health outcomes were assessed, but no differences in outcomes were found, with a low uptake of the intervention also reported in this study.


By contrast, another UK trial, this time of a revision to the universal provision of routine community-based midwifery care, did find significant differences in maternal health outcomes. MacArthur and colleagues12


practice clusters were recruited across the West Midlands health region in England, 17 of which were randomly allocated to the intervention and 19 to the control; midwives attached to the practices recruited women and provided either the intervention or standard care; 1,087 women were recruited to the intervention and 977 to the control. Primary study outcomes included maternal physical and psychological health as measured using the SF36 and the EPDS. As part of the intervention, midwives planned when they would visit women at home based on individual need and extended the duration of contacts with all women to 28 days. Women were asked about their experiences of common health problems at around 10–12 days and 28 days after birth, with access to evidence-based guidelines to support clinical management.13


The routine contact with


the family doctor at six to eight weeks was replaced with a midwife home visit at 10–12 weeks, at which point women were discharged from maternity care. At four and 12 months post-birth, psychological health measures were significantly better among women who had received the new model of care and consultation rates with family doctors were significantly reduced, with no differences in uptake of infant immunisation or consultations to discuss contraception. The researchers recommended that the new model of care should be adopted as routine within the NHS, given that the outcomes were clinically improved and the intervention was cost-effective.


Revisions to the traditional model of care are also required if we are to improve women’s experiences of care. A recent survey by the National Perinatal Epidemiology Unit14


reported that 70 % of over 5,000


women who responded found their inpatient stay following birth ‘about right’, but only around 50 % of the women felt they were ‘always’ treated as an individual by staff on the post-natal wards. A large survey of 1,260 self-selected first-time mothers undertaken by the National Childbirth Trust (NCT)15


identified widely varying


standards of post-natal care across the acute and primary care sector. While there was some positive feedback – for example, 83 % of women felt they were treated with respect – several areas of concern were raised. Around one in eight women was critical of their care, reporting inconsistent advice, lack of emotional support, inadequate assessment of their needs and too few home visits. Women who had a Caesarean birth were least satisfied with the level of care received. One in four women was critical of the help and support they received with infant feeding.


Particular concerns have been raised about the provision of inpatient post-natal care. As part of a systems and process review to inform a quality improvement project in one large English NHS trust, 20 women were interviewed about their experiences of inpatient care.16


Women referred to a lack of information on what to expect from inpatient post-natal care, a lack of understanding of how care was organised (including why ward lights needed to be switched on at six o’clock in the morning and not switched off until midnight), and most reported low expectations of inpatient care. Ward staffing levels were an issue, as some women reported that they did not want to bother midwives with any issues or concerns they had, as they could see that staff were ‘too busy’.


undertook a cluster randomised controlled trial to compare standard community-based post-natal care with a new model of midwifery-led, protocol-based care. Thirty-six general


EUROPEAN OBSTETRICS & GYNAECOLOGY SUPPLEMENT


Recognition of the need to enhance the quality of NHS maternity services to ensure services are safe and supportive and meet the individual needs of women and babies has been at the core of recent maternity services policy. The Department of Health’s 2007 publication Maternity Matters17


recommended that women should 23


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