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postnatal care supplement

Implementing the NICE guideline on postnatal care

Yana richens

Postnatal care: what matters to midwives

ruth cattrell, tina lavender, akhtar Wallymahmed, carol Kingdon, Julie riley

Seeking to explore what matters to women about postnatal care

Julie Wray

Postnatal caesarean care: evaluating the skill mix

Jackie Baxter, alison Macfarlane

Support for infant feeding: mothers’ perceptions

patricia a cairney, elizabeth M alder, rosaline s Barbour

Implementing the NICE guideline on postnatal careBy Yana Richens

The guideline Postnatal care: routine postnatal care of women and their babies was published in 2006 to provide midwives, health care professional,

women and their families the essential core (routine) care that every woman and her baby should receive in the first 6–8 weeks after birth, based on the best evidence. As high-lighted in the National Service Framework (Department of Health, 2004:33) this is usually 6–8 weeks after the birth, but this should be for a least a month after birth or transfer from hospital, and up to three months or longer depending on individual need. This is reflected in the Midwives Rules and standards (Nursing and Midwifery Council, 2004:7)

What is the purpose of a national clinical guideline? Its purpose is: n To provide practitioners with an evidence-based guide to

practicen To improve patient caren To assist practitioners and patients to make decisions

about care and treatment.There are four overriding principles in the guideline that form the basis for care and which highlight that women and their families need a service based on their individual physical, psychological, emotional and social needs:n Women and their families should be treated with kind-

ness, respect and dignity at all times n The views, beliefs and values of the woman, her partner

and her family in relation to her care and that of her baby should be sought and respected at all times

n The woman should be fully involved in planning the timing and content of each postnatal care contact

n All actions and interventions carried out on the mother

or baby at any time in the postnatal period need to have been fully explained and informed consent obtained.As NICE continues to publish clinical guidelines, the

term ‘clinical guideline’ is now an integral part of the medical vocabulary. However the term ‘implementation’ may not be as familiar, and yet increasingly midwives are tasked with implementing clinical guidelines. This article highlights the key implementation points of the Routine Postnatal Care Guideline (NICE, 2006), and suggests a way that compliance of the guideline can be measured.

There is no doubt that when implemented success-fully, guidelines can have a positive effect on the quality of care given to women. Implementation can be difficult to achieve, and midwives may require some awareness and information on implementation strategies.

A selective literature review on guideline implementa-tion has been conducted (Richens and Rycroft-Malone, 2004), the aim of which was to identify the most effective approaches to implementing clinical guidelines into nurs-ing practice. Several key points emerged from the review:n Guideline developers should develop recommendations

that are clear, specific and relevant to practitioners and practice. This also applies to the local adaptation of national clinical guidelines.

n Building partnerships between guideline developers, users and implementers may assist in ownership and subsequent adoption of the guideline.

n Interactive, targeted education interventions may be effective in developing practitioners’ knowledge, skills and attitudes about a guideline’s recommendations. This may be a particularly useful strategy in translating national guidelines to local circumstances.

n Having a dedicated ‘change agent’ who works with and supports individuals, teams and organizations in the practice context is likely to facilitate guideline imple-mentation.

n Clinical audit has an important role to play in guideline implementation.

n Guideline implementers need to pay attention to organi-zational factors to ensure the implementation plans fit in with the organization’s strategy and resource commit-ments. Closs and Cheater (1997:9) suggest that implementa-

tion:‘involves activities that turn guidelines into action, influencing clinical decision making and behaviour; such activities aim to encourage practitioners to change their clinical practice in line with the guideline’.

Yana Richens is Consultant Midwife at Elizabeth Garrett Anderson & Obstetric Hospital, University College London Hospitals NHS Trust, LondonEmail: [email protected]

AbstractWhen implemented into clinical practice guidelines can have a positive effect on the quality of care provided to mothers and babies. This article highlights some of the key points for implementation of a national guideline into clinical practice.

412 British Journal of Midwifery, July 2007, Vol 15, no 7

CLINICAL

The implication is that by implementing guidelines, changes to practice will occur, which will result in the improvement of patient care and outcomes (NHS Centre for Reviews and Dissemination, 1994). While evaluations of the effect of clinical guidelines have demonstrated some improvement in quality of care (e.g. Grimshaw and Russell, 1993), whether this is achieved in daily practice is less clear (Thomas et al, 1999). Guideline implementation continues to be a major challenge for those working in the health serv-ice, with scientific, organizational and behavioural factors influencing whether implementation is successful (Kitson et al, 1998; Ferlie et al, 1999).

Implementing the guideline on routine postnatal caren National implementation strategies often remain on a

grand scale, leaving smaller regional teams to carve out feasible local plans for themselves. The question that almost all commissioners and providers ask once a new national guideline is published is: ‘What do we need to do as an organization to implement this guideline?’ Whereas individual staff members may ask: ‘How does this affect me and what do I do?’ Duff et al (2000) have developed a six step guide which

can be used as a framework for implementing evidence in practice (Table 1).

Key priorities for implementationThe following key priorities for implementation have been taken directly from the guideline (NICE, 2006) n A documented, individualised postnatal care plan should

be developed with the woman ideally in the antenatal period or as soon as possible after birth.

n This should include: relevant factors from the antenatal, intrapartum and immediate postnatal period details of the healthcare professionals involved in her care and that of her baby, including roles and contact details plans for the postnatal period.

n This should be reviewed at each postnatal contact. n There should be local protocols about written commu-

nication, in particular about the transfer of care between clinical sectors and healthcare professionals. These pro-tocols should be audited.

n Women should be offered relevant and timely informa-tion to enable them to promote their own and their babies’ health and well-being and to recognize and respond to problems.

n At the first postnatal contact, women should be advised of the signs and symptoms of potentially life-threatening conditions and to how contact their healthcare profes-sional immediately or call for emergency help if any signs and symptoms occur.

n All maternity care providers (whether working in hos-pital or in primary care) should implement an exter-nally evaluated, structured programme that encourages breastfeeding, using the Baby Friendly Initiative (www.babyfriendly.org.uk) as a minimum standard.

n At each postnatal contact, women should be asked about their emotional well-being, what family and social sup-port they have and their usual coping strategies for deal-ing with day-to-day matters. Women and their families/partners should be encouraged to tell their healthcare professional about any changes in mood, emotional state and behaviour that are outside of the woman’s normal pattern.

n At each postnatal contact, parents should be offered information and advice to enable them to:

– assess their baby’s general condition – identify signs and symptoms of common health prob

lems seen in babies – contact a healthcare professional or emergency service

if required. Table 2 is an example action plan for people working to

implement this guideline in acute and primary care trusts and for commissioners.

Table 3 identifies the key priority areas for implementing the guideline on postnatal care which will be used by the Healthcare Commission to measure an organization’s com-pliance with the guideline, once you have worked through the guideline and discussed in your team where you are with the implementation process.

Table 4 attempts to highlight how the new NICE guideline on antenatal perinatal mental health could be implemented by asking three key questions (Richens et al, 2007):n What does the guideline say?n What do we have to do to implement it? n How will it benefit the women we care for?These are then put into a clear table and used as a basis for implementing the main recommendations of the guideline to users.

The ultimate responsibility for implementing this guideline rests with the chief executives of organizations responsible for commissioning and delivering mater-nity and child health services. Midwives can use clinical governance mechanisms to ensure that action plans and progress with the implementation of this guideline are reported back at individual board level. Areas of non-com-pliance of the guideline should be recorded Remember that guidelines are tools for practice, they are not rules and it may be that you have a good reason for not using and implementing a part of the guideline locally. If this is the case then you need to be able to justify your reasons for doing this Furthermore you need to remember that Compliance of the guideline is monitored by the Health Care commission.

step 1 - deciding who will lead the workstep 2 - determining where you are now (both the con-text and in clinical practice through clinical audit)step 3 - Preparing to implement the guidelinestep 4 - identifying techniques to assiststep 5 - devising an action planstep 6 - evaluating your progress

Table 1. Six steps to improving practice

Angela Grady: Linda’s experi-ence in her own words

British Journal of Midwifery, July 2007, Vol 15, no 7 413

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Recommendation Key area number Actions for consideration Communication 1.1.1 n attend relevant local meetings, including user group meetings, to share the guideline and the action plan. we have developed slides to help you. 1.1.2 n review local postnatal care plans and protocols about written and verbal communication as part of your baseline assessment. 1.1.4 engaging with relevant professional groups, networks and other service providers might help you to obtain consensus on strategies for verbal and non-verbal 1.1.6 handover of care and how this can be audited. n Consider how the role of postnatal coordinator can be clearly identified by women 1.1.8 and their families and ensure that there is a mechanism for identifying the named postnatal coordinator within the care plan. 1.1.9 n work with others to consider any changes in the design and content of existing postnatal care plans and other written documents and ensure that the format facilitates the sharing of holistic information, including social complexity triggers. decide who should be involved in this work; key partners are likely to include midwives, health visitors, general practitioners, mental health services, relevant local health initiatives (including sure start and local authority leads) and service users. Consider any costs related to developing or amending local documentation n ensure that adequate midwifery documentation detailing pertinent antenatal and intrapartum information is held by the woman until discharge from midwifery care to facilitate effective communication and care. n ensure that the personal child health record is given to all women within the first three days of birth and its use explained* information 1.1.5, 1.1.6, n review local supplies and distribution of Birth to five as part of your baseline Provision 1.1.7, assessment. the costing template can support work to identify costs of providing Birth to five to all mothers.* 1.2.1, n review local information leaflets; check they are up to date and relevant to your 1.2.69, 1.4.1 local community and minimize conflicting advice. n ensure that women and their families are informed about how to access local information provision across a range of settings such as sure start centres, libraries and nhs walk-in centres. implementing an 1.3.3 n it is recommended that this programme uses the Baby friendly initiative as a externally minimum standard. More information on the Baby friendly initiative is available evaluated 1.3.4 on its website.* structured n use the niCe costing tools to assess costs and savings. programme that n use the evidence into Practice briefing ‘Promotion of breastfeeding initiation and encourages duration’ to learn more about effectively supporting groups who are breastfeeding less likely to breastfeedtraining and 1.1.10 n attend relevant local meetings to share the guideline and the action plan. we have competencies developed slides to help you. 1.2.22 n review competencies of all staff as part of your baseline assessment. n ensure that the guideline recommendations are linked to Clinical negligence scheme 1.2.62 for trusts (Cnst) standards for maternity. review performance regularly alongside these standards.* 1.2.67 n Plan a training programme to ensure relevant competencies developed by skills for health are met. Collaborate with your local workforce development directorate, higher 1.4.9 education institutions and trust training teams to review the content of existing training programmes. n ensure recommendations are incorporated into existing and new continuing professional development programmes. Consider pre-registration training, training for new staff including induction, and updating for existing staff.*suggested actions specifically aimed at commissioners source: niCe website http://guidance.nice.org.uk/page.aspx?o=345145

Table 2. Example action plan


CLINICAL

How will it benefit Recommendation What do we have to do to implement it? the women we care for?Predicting ask women in your care about: identifying women at high risk of perinatal mental n Previous or current serious mental illness mental illness during pregnancy or illness n Previous treatment by a psychiatrist or specialist mental postnatally helps staff to identify health team, including inpatient care any problems early. n family history of mental health problems in the antenatal and postnatal periods. do not use other factors, such as a poor relationship with a partner, to predict mental illness.detecting when a woman makes initial contact with services and the evidence supports asking depression postnatally (at 4–6 weeks and 3–4 months) ask: three brief questions rather than n during the last month, have you often been bothered by longer and more complex methods feeling down, depressed or hopeless? because they are as effective and n during the last month have you often been bothered by are more compatible with routine having little interest or pleasure in doing things? use in busy primary and second if a woman indicates that she has been affected by such ary care settings (whooley et al, feelings, ask a third question: 1997; arrol et al, 2005). their n is this something you feel you need or want help with? other advantage is that they can the ePds, hospital anxiety and depression scale (hads) or be used in both the antenatal and Patient health Questionnaire-9 (PhQ-9) may be employed in postnatal periods. any ensuing mental health assessment. although there are validated tools only for the detection of depression, be vigilant for other mental health problems, such as anxiety, eating disorders, post-traumatic stress disorder (Ptsd) and obsessive-compulsive disorder.

Table 4. Implementing the guideline

Key priority for implementation Met Partially Met Not Met Commentsa documented, individualized postnatal care plan should be developed with the woman ideally in the antenatal period or as soon as possible after the birth. this should include: n relevant factors from the antenatal, intrapartum and immediate postnatal period n details of the healthcare professionals involved in her care and that of her baby, including roles and contact details n Plans for the postnatal period this should be reviewed at each postnatal contact.there should be local protocols about written communication, in particular about the transfer of care between clinical sectors and healthcare professionals. these protocols should be audited.

(niCe, 2006)

Table 3. Example of measuring compliance

CLINICAL


How will it benefit Recommendation What do we have to do to implement it? the women we care for?referral if mental if there are significant concerns refer to the woman’s GP. Clear referral pathways will enable illness is in cases of severe mental illness, refer to a specialist mental women with identified or suspected or health service, including a specialist perinatal mental health suspected mental health there are service, and discuss with the woman and preferably with her GP. problems to benefit from effective significant concerns even if no further assessment or referral inform the GP. assessment and treatment as about a woman’s if the woman does have a current mental disorder or a soon as possible. mental health history of severe mental illness, ask about her mental health at every contact. a care plan covering the antenatal and postnatal periods and delivery should be developed in the first trimester in collaboration with the woman and relevant professionals; the plan should include increased contact with specialist mental health services. explaining risks of discuss with a woman taking an antidepressant options that women may be worried that psychotropic will allow her to breastfeed if she wishes, rather than taking drugs will harm their baby, medication recommending not to breastfeed, following advice from their either during pregnancy or through doctor. breastfeeding. the guideline is very clear that while the risks for the baby with some drugs are relatively well established, for many drugs, particularly most antidepressants, the risks are still only poorly understood. however, there is usually no good reason why women cannot breastfeed. encourage pregnant women who are thinking of stopping their psychotropic medication to discuss it with their doctor and to it is very important that women follow advice on how to stop drugs safely. are given relevant information to make informed choices about drugs at this time, balancing her individual risk factors with those of the drugs. for some women the risk of untreated illness is greater than that posed by drugs, for example, she may have a history of relapse leading to inpatient care and little support at home in the event of such an emergency. Many women stop taking their drugs abruptly on discovering they are pregnant which may be detrimental to their health and that of their baby. all professionals involved in such discussions must have not only up-to-date knowledge of the risks associated with different courses of action but also skills in the communication, assessment and management of clinical risk.

Table 4. Implementing the guideline (continued)

ConclusionAlthough one might expect that the responsibility of local implementation for the guideline on routine postnatal care will mainly fall to midwives, NICE provides a suite of implementation tools to support the guideline. This includes a slide-set that can be tailored to local needs; it

focuses on the key priorities for implementation Another tool from the suite that will prove very useful

to help with implementation in midwifery services is the audit tool, which outlines how to audit whether a service is complying with the NICE guidance. These are available from the website. BJM

CLINICAL


Key Pointsn Clincal guidliens provide practitioners with an evidence based

guide to use in clinical practice.n Implementation of guidelines continues to be a major

challenge.n Clinic audit has an important role to play in guideline

implementation.n Clinical guidelines are tools for practice and not rules.

Further reading Quick reference guide: www.nice.org.uk/037quickrefguideNICE guideline – all of the recommendations: www.nice.org.uk/CG037niceguidelineFull guideline – all of the evidence and rationale: www.nice.org.uk/CG037fullguideline‘Understanding NICE guidance’ – a plain English version: www.nice.org.uk/CG037publicinfo

ArrollB, Goodyear-Smith F, Kerse N, Fishman T, Gunn J (2005) Effect ot the addition of a ‘help’ question to two screening questions on specificity for diagnosis of depression in general practice, diagnostic validity study British Medical Journal 331: 884Closs SJ, Cheater FM (1997) The effectiveness of methods of dissemination and implementation of clinical guidelines for nursing practice: a selective review. Clinical Effectiveness in Nursing 1: 4–15Department of Health (2004) National Service Framework for Children, Young People and Maternity Services: Standard 11, Maternity Services. Department of Health, London: [http://www.dh.gov.uk/asset-Root/04/09/05/23/04090523.pdf ]Closs SJ, Cheater FM (1997) The effectiveness of methods of dissemination and implementation of clinical guidelines for nursing practice: a selective review. Clinical Effectiveness in Nursing 1: 4–15Ferlie E, Wood M, Fitzgerald L (1999) Some limits to evidence-based medicine: a case study from elective orthopaedics. Quality in Health Care 8: 99–107Grimshaw JM. Russell IT (1993) Effect of clinical guidelines on medi-cal practice: a systematic review of rigorous evaluations. Lancet 342: 1317–22Harrow D, Foster J, Greenwood J (2001) Evidence and leadership: the tools for change. Contemporary Nurse 11: 9–17Kitson A, Harvey G, McCormack B (1998) Enabling the implementation

of evidence-based practice: a conceptual framework. Quality in Health Care 7: 149–58NHS Centre for Reviews and Dissemination and Nuffield Institute for Health (1994) Implementing clinical guidelines: can guidelines be used to improve clinical practice? Effective Health Care 1: 1–12Nursing and Midwifery Council (2004) Midwives Rules and stand-ards [Accessed 24June 2007]http://www.nmc-uk.org/aFrameDisplay.aspx?DocumentID=169Richens Y, Rycroft-Malone J (2004) Getting guidelines into practice: a lit-erature review. Nursing Standard 18: 33–40Richens Y, Burbeck R, Shackleton B Taylor C (2007) Implementation: use of the guideline. Midwives Bol 10(6): 280–1 http://guidance.nice.org.uk/page.aspx?o=345145 [accessed 24 June 2007)Thomas et al (1999) Clinical guidelines in nursing midwifery and the therapies, a systematic review Journal of Advanced Nursing 30 1 40-50Whooley MA, Avins AL, Miranda J Browner WS (1997) Case finding instruments for depression Two questions are as good as many. Journal of General internal Medicing 12: 439–45

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206 BRITISH JOURNAL OF MIDWIFERY, APRIL 2005, VOL 13, NO 4

It is a statutory requirement that a mid-wife attends a mother who has givenbirth for a period of not less than ten

days and not more than twenty-eight days(UKCC, 1998). This is determined locallyand systems vary greatly within the UK.

Changing Childbirth (Department ofHealth (DH, 1993) caused the midwiferyprofession to re-evaluate the provision ofmaternity care. However, this re-evalua-tion concentrated on antenatal andintranatal care. There was little referenceto postnatal health except for limitedrecognition that postnatal continuity ofcare was deemed important. Little haschanged in postnatal care in the last ten years.

Alexander et al (1990) stated that theprovision of postnatal care uses approxi-mately 50% of the total revenue budget inobstetric care within the UK. This is some-what of a paradox, as postnatal care isperceived by the profession as not being amajor priority. There is little evidence tosupport this extent of financial commit-ment to this element of care. Similarly,there is little to allow us to state that itsabandonment or drastic revision is valid.

The value of routine postnatal care, inits current format, has been questioned

(Marchant and Garcia, 1995).Interestingly, midwives have continued toprovide care in a ritualistic fashion whilevoicing concern at the value of this careprovision (Bick, 1995). Midwives have aunique role within the primary care teamand should have awareness of individualwomen’s cultural, social, physical andemotional needs. Twaddle et al (1993)however, discusses that this is certainlynot the case, and anecdotal evidence fromboth women and midwives substantiatesthis view.

The poor delivery of postnatal care inthe hospital and community setting hasbeen identified in UK Government reportsand by national bodies (AuditCommission, 1997; Royal CollegeMidwives, 2000). Prioritizing research intoeffective postnatal care has also been recommended (Audit Commission, 1997).

Midwives generally allocate more timeto the physical aspects of postnatal carethan they do to psychological and socialsupport (Marsh and Sargent, 1991).However, Bick (1995) recommends thatreducing routine postnatal examinationswould release midwifery time to provideopportunities to discuss and addresshealth problems and other concerns ofnew mothers. Yet, the importance ofwomen being able to talk about theirexperiences of childbirth has been high-lighted in a number of studies (Bick, 1995;MacArthur et al, 1997; Charles and Curtis,1994; Lavender and Walkinshaw, 1998).Indeed, one of the few studies to ade-quately assess a postnatal intervention, ina well-conducted cluster randomised con-trolled trial, (MacArthur et al 2002), foundthat at 4 months postnatal, women whohad received individualized, midwife-ledcare for a period of 3 months hadimproved mental health scores whencompared to those who received routine care.

PROFESSIONAL ISSUES

Postnatal care: what mattersto midwivesBy Ruth Cattrell, Tina Lavender, Akhtar Wallymahmed, Carol Kingdon, Julie Riley

ABSTRACTThere has been little change in the provision of postnatal care over the lastdecade. Yet anecdotal evidence suggests that midwives are increasinglyconcerned about the service they are providing. This study aimed toexplore midwives perceptions of the current provision of postnatal care inthe North West of England. A stratified random sample of 26 midwivesworking in a hospital or community setting attended five focus groupinterviews. Qualitative analysis was undertaken using an open codingmechanism to identify emergent themes. The main themes generated werepriorities in postnatal care, societal influences and job satisfaction. This paper will use the views of midwives to debate the way forward inpostnatal care.

Ruth Cattrell is researchmidwife at LiverpoolWomen’s Hospital;Professor Tina Lavenderis reader of midwifery atthe University of CentralLancashire; AhktarWallymahmed is principallecturer at Liverpool JohnMoores University; CarolKingdon is researchfellow at the Universityof Central Lancashireat Liverpool Women’sHospital and Julie Riley isthe business manager atGlan Clywd Hospital,formerly head ofmidwifery at LiverpoolWomen’s Hospital.

This article was acceptedfor publication on 24February 2004

BRITISH JOURNAL OF MIDWIFERY, APRIL 2005, VOL 13, NO 4 207

Most previous literature has failed toexplore views of midwives in parallel tothose of the women. We therefore decidedto explore the views of both groups to gaininsight into their perceptions of the effec-tiveness of postnatal care. This paper willpresent the findings of the midwives‘views.

Study aimsThe overall aim of the study was toexplore midwives’ perceptions of the cur-rent provision of postnatal care both in thehospital and community. Specific areas ofinterest included: ■ Midwives perceptions of the current

role of the midwife;■ The potential role of postnatal support

workers;■ The perceived benefits of the physical

examination;■ Issues around the provision of emotional

support; and■ Multi-professional collaborations.

MethodThe study took place in a north westregional teaching hospital undertaking

approximately 6000 deliveries per year.Hospital postnatal care takes place in oneof three areas. Women with straightfor-ward pregnancies and childbirth aretransferred from delivery suite to singleroom accommodation for approximately24–72 hours prior to transfer to communi-ty midwives. In contrast ‘high-risk’ moth-ers and those with complicated deliveriesare transferred to a high dependency post-natal ward comprising 6-bedded bays.Low-risk mothers who give birth withinthe midwifery-led unit remain in theirown room until transfer home.

EthicsPrior to the commencement of the study,full ethical approval was obtained fromthe Local Research Ethics Committee andTrust Research and Development commit-tee. The midwives’ perspective wasobtained through a qualitative exploratoryapproach utilising focus groups. Focusgroups have been shown to be beneficialin evaluating a service (Morgan andKrueger, 1993). Although the researcher’scontrol is limited in focus groups, the dis-cussion may be dominated by individualswho can introduce an element of bias,

POSTNATAL CARE

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allocate moretime to thephysical aspectsof postnatal carethan they do topsychologicaland social side

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processing package. Analysis was under-taken using an open coding mechanism toidentify emergent themes, in a processsimilar to grounded theory analysis(Strauss and Corbin, 1990). Tworesearchers (RC, TL) viewed the data andindependently generated themes from theresponses to minimise interpreter bias.These were then collated and individuallydiscussed until a consensus was reached.

ResultsForty midwives were invited to participatein the focus groups, 65% (n=26) of whichattended. Five focus groups were conduct-ed, as illustrated in Table 1 (overleaf).

Regardless of clinical grade or area ofwork midwives shared the same views. Asthe groups generated similar themes, theresults will be presented as a whole.Verbatim comments from the transcriptsare used to illustrate the main findings.Main themes identified were priorities inpostnatal care, societal influences and jobsatisfaction.

Priorities in postnatal careMidwives’ focus groups discussions, cen-tred on physical and emotional support forwomen and information provision.

Physical support for womenMidwives believed that women wereunaware of the physical changes thatoccur following childbirth and as suchmuch support was often required.Midwives were generally supportive of aregular physical assessment both in termsof observing problems and as an introduc-tion to discussion. For example, one midwife said:

‘If you go into a room to examine awoman she will often ask youquestions as you go along, but if youjust say “do you have any problems?”she is likely to say no.’

However, some midwives expressedconcerns about the nature of physical careschedules. They said that they hadbecome so routine that it made certainshifts unmanageable:

making participants compliant with theirviews. To reduce these factors the focusgroups consisted of midwives working inthe same clinical area at the same clinical grade.

SampleMidwives were randomly selected by com-puter-generated numbers assigned to per-sonnel records, stratified according toarea of work (hospital or community).These midwives were invited by letter toparticipate with the option given for themto discuss it further if they wished. Themidwives were given the choice of allocat-ed time or remuneration to attend the ses-sion. Eight midwives were invited to makeup each focus group.

The number of focus groups was deter-mined by the generation of new themes.New focus groups were initiated until theresearchers were reasonably satisfied thatthey had exhaustively analysed the theoretical ideas emerging from the participants (Flick, 2002).

A university lecturer (AW), who was nota midwife, acted as facilitator and aresearch administrator (CK) acted asscribe. These were independent of theMaternity Directorate therefore there wasno conflict of interest and the chance ofbias was minimised.

A semi-structured approach was used,the interview schedule compiled from thecurrent literature, and issues debated atlocal and national forums. The focusgroups were tape-recorded following ver-bal consent from the participating mid-wives. It was reiterated that the focusgroups were confidential.

The audio tapes were transcribed ver-batim prior to being entered into a word


Throughoutsociety

there is amisconceptionthat particulargroups needmore support.We are lesslikely to expectprofessionalmothers to need help

‘

’

Focus group Clinical area Clinical grade NumberAttended

1 Community group G 5

2 Community group G 7

3 Hospital G 6

4 Hospital F 2

5 Hospital E 6

Table 1. Midwife participants

‘Everything has to be done in themorning…It is like a race to get allyour checks done, discharges done andpaper work done before the next shift.What happened to individualised care!’

It was thought that visiting times (from13:30–15:00) prevented midwives fromspreading the workload between shiftstherefore limiting the actual time spentwith women.

‘I suppose I’m stuck in my ways but onthe late shift the visitors see you assomeone to get vases for them and theyresent you doing checks.’

The content of physical assessmentswas discussed. Midwives suggested that ‘itis important that we have a top-to-toecheck list for mums and babies so thatthings don’t get missed out’. Othersbelieved that a more individualisedapproach was required which encouraged‘personal assessment according to need’.

Emotional support for womenAll midwives acknowledged the need forimprovements in emotional support forwomen in the postnatal period. They iden-tified that women often felt vulnerable fol-lowing childbirth and believed that‘women were already starting off withtheir coping mechanisms low’. It wasreassuring to know that midwives high-lighted the need to identify early signs ofpostnatal depression:

‘It is important for midwives to pickup potential or early signs of problemsto be effective in helping prior to itdeveloping into a major problem.’

Midwives used the term ‘debriefing’ forcommunicating important information towomen in their care. They saw it as animportant role of the midwife that shouldbe widely available to women. They com-mented that ‘women complain that they arenot debriefed’. Communicating with andsupporting women is important. However,lack of midwifery time was thought to bethe biggest barrier to emotional supportand midwives felt frustrated that ‘there isnot as much debriefing as we would like’.

InformationMidwives generally felt that preparationfor parenthood was inadequate. A reor-ganisation of sessions so that there wasappropriate information available to allwomen and fathers was also suggested:

‘There is a need for parent educationto be reorganised incorporatingdifferent styles: to include fathers; bein small groups; facilitate ‘drop in’sessions; to be accessible and benefitthe traditional non-attendees.’

Midwives also identified that parenteducation should be available at schools,to inject some realism into youngwomen’s views of motherhood. Postnataleducation in general was believed to be‘superficial’ and ‘provided too late’, forexample:

‘Postnatal education is too late when amother is upset when breastfeeding isnot progressing according to herexpectations.’

Midwives believed that peers could havea great influence on mothers and could beinstrumental in providing appropriate

POSTNATAL CARE


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information. Talks by other mothers wassuggested as a way to help women identifytheir own realistic expectations.

Furthermore, consistent informationprovision from hospital and communitygroup midwives was considered a priority,and pivotal to providing a seamless service to women.

Societal influencesMidwives discussed postnatal care in thecontext of today’s society, recognising theimpact of societal expectations, the mediaand support mechanisms on women’sexperiences.

Societal expectations of womenMidwives believed that in order to viewthe role of motherhood, it was first neces-sary to consider the role of women intoday’s society. They believed that societydemands a great deal from women. Thismeans ‘some women put on a brave face’to project an image that they believe isacceptable to family, friends and health professionals.

Midwives felt that society had changedto an extent that role adaptations areincreasingly difficult and demanding tomothers in different ways. For example,an increase in teenage pregnancies wasthought to isolate young women fromtheir peers. Yet working mothers werebelieved to have different burdens in rela-tion to achieving ‘perfect parenthood’ and‘career status’ simultaneously. Theseissues have been confounded by the lackof extended families. One midwifeexpressed this in the following way:

‘Throughout society there is amisconception that particular groupsneed more support. But we are lesslikely to expect professional mothers toneed help. Society should ensure thatindividualised postnatal care isavailable – whether you are young,unmarried and living with yourmother or a professional woman whohasn’t got any family support.’

Midwives in some areas were con-cerned for the women who were unable toarticulate themselves fully. It was felt that

the present system was failing some ofthose women.

However, in other areas midwives stat-ed that ‘there were good measures inplace for minority groups, but little sup-port for the majority of women using theservice’. These conflicting views perhapsdemonstrate the inconsistency of careoffered to women in one city. Some mid-wives believed that because of the ‘lack ofextended families some women expect toomuch from midwives’. But many midwivesspoke positively about trying to fulfil theneeds of women by working in close partnership with them:

‘It can be satisfying to establish what awoman wants and work with them toachieve this.’

Media influenceMidwives believed that the media provideswomen with unrealistic expectations ofmotherhood. One commented:

‘The image of motherhood, babies andfamily life is unrealistically portrayedthrough media adverts portrayingsmiling mothers and babies.’

It was felt that women’s expectationsshould be realistic and that the media,books and glossy magazines do not por-tray a realistic image. It was identifiedthat women were quick to complain, andmidwives stated that they have to beaware of this in their everyday practiceand in the information they provide.

Societal supportThe need for support for women wasexpressed in all focus groups. Suggestionswere put forward for improving socialsupport postnatally. These includedgreater links with consumer groups suchas the National Childbirth Trust, as it wasfelt that they ‘are ideally positioned tooffer support in the community’.

Another recurrent suggestion was theneed for midwives to facilitate the provi-sion of links with peer supporters to pro-vide information and support for mothers:

‘There is a need to initiate a supportnetwork of mothers who encountered

PROFESSIONAL ISSUES


Home helpswere discussed

as a potentialform of supportfor women as itwas believedthey could relievenew mothers ofhouseholdburdens

‘

’

POSTNATAL CARE


similar life experiences, thus enablingthem to support each other.’

Home helps were also discussed as apotential form of support for women as itwas believed that they could relieve newmothers of household burdens. Midwivesstated, however, that ‘childbearingwomen are not seen as a priority for this service’.

Job satisfaction formidwivesPersonal satisfactionMidwives felt that individual care wasimportant and that it was satisfying toestablish what a woman wants and towork with her to achieve this.

‘Individual care requires adaptation toinitiate a tailor-made service meetingthe needs of individual mothers.’

It was apparent that midwives gainedjob satisfaction from caring for a womanthey knew and being able to provide goodcontinuity of care. One midwife spoke onbehalf of others when she said:

‘We feel valued when we are successfulin sorting out problems. It means wecan improve the experience of womenin our care.’

The present system of community visit-ing (which was GP attached) was per-ceived as not providing satisfactory conti-nuity of care for women. Midwives feltfrustrated, as they believed that ‘continu-ity was better, in the previous system,when midwives were geographicallyplaced.’ An increase in midwives’ travel-ling time between homes was believed toreduce the amount of time for midwife-woman contact.

Barriers to satisfactionIt was felt that there are increasingdemands on midwives time. In particularmidwives felt they spent a lot of unneces-sary time on administrative duties.

‘A great deal of time is spent using thecomputer. Midwives could do a lot of

work with the mother instead of work-ing on the computer.’

The role of maternity aids was discussedin all focus groups and although midwivessaw them as a potential support, theyappeared protective and concerned aboutthe possible erosion of the midwifery role.

‘The role of NVQ or maternity aids wasseen as a support to midwives, not todo midwifery things.’

Time constraints also arose from theperceived ‘lack of staff’ in some areas.Worryingly, it was felt that when midwiveswere busy their body language conveyedthis to mothers and this resulted in moth-ers ‘not wishing to bother the midwife toask questions or ask for help’.

Furthermore, midwives felt that they didnot always anticipate problems becausethey were too busy to be able to spendtime talking with mothers and assessingtheir needs. There was also concern thatcare was sometimes disjointed:

‘Care appears fragmented, this leads tomidwives being unable to followthrough with a mother’s care and thislimits their continuity of care andcarer.’

Midwives believed that innovativeworking practices, such as performing the6-week postnatal assessment, wouldincrease continuity for women andenhance their own job satisfaction.

‘It (the 6-week postnatal exam) wouldbe beneficial to mothers as themidwives could build upon the goodrapport they had already established.’

However, they felt strongly that the fun-damental role of providing physical andemotional support to women for up to 28days postnatal had to be improved prior toany role extension.

Feeling valuedWhen discussing job satisfaction mid-wives said that they appreciated verbaland written tokens of appreciation fromwomen or their families:

It appearsthat a major

barrier topostnatal care isthe unnecessarytime spent bymidwives on non-midwifery duties

‘’

‘The little things make all the difference.We appreciate thank you cards, hugsand positive letters.’

In contrast, midwives often knew whenthe service that they had provided hadbeen inadequate. This was despite know-ing that they had worked hard throughouta busy shift, midwives felt undervaluedwhen they perceived that they had not metthe women’s needs:

DiscussionThis exploratory study provided anoverview of the views of midwives workingwith women in the postnatal period, in onepart of England. Restricting the inquiry to asingle area may limit its applicability toareas using different models of postnatalcare. Nevertheless, issues raised by themidwives are topical, timely, and warrantfurther investigation.

Only 65% of midwives invited, attendedthe focus groups despite being offered timein lieu or remuneration. This may havebeen due to work demands. Non-attendeesmay have had different views. However, allthe midwife grades within the trust wererepresented. Moreover, the same ethicalconsiderations apply to midwives as towomen participating in research studies(DH, 2001). Thus an individual’s right todecline participation in any study shouldbe respected.

It was reassuring to find that midwiveswere willing to talk openly within the focusgroups. However the fact that the facilita-tor and scribe were independent appearsto have enabled the midwives to expressand voice their opinions uninhibited. Thiswas evident by the comments made.

Midwives’ acknowledgement of societalinfluences on women in general and post-natal care in particular, highlights a broad-er outlook on maternity care than perhapsexpected. This is encouraging with theemerging public health role of the mid-wife, which advocates a role incorporatinga wider acceptance of the continuum ofhealth (DH, 1999). Midwives must becomeinvolved in the wider health agenda anduse their knowledge to inform and educatesociety on the needs of women. Thisshould involve advising the media.

There appears to be a dichotomy of whatmidwives want to provide and what theyare actually providing. In hospital andcommunity, midwives continue to providecare in a ritualistic fashion so that they can‘tick the appropriate boxes’. This theyacknowledge to be unsatisfactory. But withthe national shortages of midwives, it isimportant to look at ways of tacklingresulting service issues. One way toimprove care is to either delegate non-essential midwifery roles or find new waysof working in order to make the most oflimited staffing resources.

It appears that a major barrier to postna-tal care is the unnecessary time spent bymidwives on non-midwifery duties.Supporting the view that midwives may notbe able to offer the full range of midwiferycare unaided (Magill-Cuerden, 1994). Yetmidwives must be willing to delegate suchroles to appropriate health care assistants.The evaluation project by Garcia (1997)found that 45% of midwives questionedbelieved that non-midwife carers could domore in the postnatal wards. In this cur-rent study midwives wished to relinquishthemselves of clerical duties but werereluctant to delegate clinical duties.

Midwives do not work in isolation but aspart of a multidisciplinary team, particu-larly in the community setting.Interestingly, midwives did not suggesttheir professional peers, e.g. health visi-tors, school nurses, GPs as providing post-natal support. This may be, as suggested inan earlier survey, that health professionalsare worried about the lack of multi-profes-sional boundaries and concerned that theymay ‘step on toes’ (Lavender et al, 2002).Yet, their role within primary care trustsputs them in a good position forworking with other professionals and thelocal community.

Midwives in this study recognised thelack of peer support for some women. Thiscould be attributed to the lack of matriar-chal role models created by reduced fami-ly sizes and ‘nuclear-family’ set ups. Yet byengaging the community, midwives couldgain allies who could provide appropriatepeer support.

Midwives suggested ‘home helps’ forwomen, although a recent randomisedcontrolled trial failed to demonstrate

KEY POINTS

■ Midwives acknowledgethat they do not alwaysprovide optimal care butare always striving toachieve it.

■ Midwives consideredphysical and emotionalcare to have equalstatus.

■ Societal values have animpact on women’sadaptation to theirpostnatal role.

■ Midwives identified astrong need foradditional administrativesupport

PROFESSIONAL ISSUES


quantitative benefits of this type of support(Morrell et al, 2000). What may be neededis more physical and emotional support,for example, with breastfeeding. A recent evaluation of 79 DH-fundedbreastfeeding projects (Dykes, 2003) suggested that this might well be a positive way forward.

Conclusion Midwives are clearly happy to do the jobthey were trained for but to achieve jobsatisfaction they need to know that theyhave carried out their role to the best oftheir ability. It was interesting to see thatjob satisfaction came from midwivesknowing they had done a good job for thefamily, not just the mother. Job satisfactiondid not come as a personal issue, only in afeeling that their care had benefited moth-ers and their families.

Physical and emotional support forwomen was equally valued by midwives,despite some reservations about the organ-isational routines. However, we remainfairly ignorant as to the impact of mid-wifery postnatal care on maternal andneonatal morbidity. Further research isrequired to explore this area further.

Although this study contains some nega-tive thoughts, midwives’ desire to improvepostnatal care is encouraging. In theChildren’s National Service Framework, postbirth recommendations are highlighted.This 10-year plan supports midwives toimplement optimum postnatal care for allwomen dependant on individual need.

Thanks to the midwives who participated inthe focus groups and midwifery managers forproviding the time for them to attend.

Alexander J, Levy V, Roch S (1990) MidwiferyPractice Core Topics 1. MacMillan,Basingstoke, Hampshire:11–13

Audit Commission (1997) First Class Delivery:Improving Maternity Services in England andWales. Audit Commission, London

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Department of Health (2001) GovernanceArrangements for NHS Research EthicsCommittees. HMSO, London

Dykes F (2003) The Department of Health InfantFeeding Initiative Evaluation of thebreastfeeding practice projects funded by theDepartment of Health between 1999–2002.Draft Report for the Department of Health.HMSO, London

Flick U (2002) An Introduction to QualitativeResearch. 2nd edn. Sage Publications, London

Garcia J (1997) Changing Midwifery Care – Thescope for evaluation: Report of a NHSE fundedproject. Evaluation of New MidwiferyPractices, Oxford

Lavender T, Walkinshaw S (1998) Canmidwives reduce postpartum psychologicalmorbidity? A randomised trial. Birth 25: 215–9

Lavender T, Bennett N, Blundell J, Malpas L(2002) Midwives’ views on redefiningmidwifery 4: general views. Br J Mid 10 (2):72–77

MacArthur C, Winter HR, Bick D, Lilford R,Henderson C, Lancashire RJ, Braunholtz DA,Gee H (2002) Effects of redesignedcommunity postnatal care on women’s health4 months after birth: a cluster randomisedcontrolled trial. The Lancet 359: 378–385

Magill-Cuerden (1994) Support the supporters.Mod Midwife 4(10):4

Marchant S, Garcia J (1995) What are we doing inthe Postnatal Check? Br J Mid 3: 34–38

Marsh J, Sargent E (1991) Factors Affecting theDuration of Postnatal Visits. Midwifery 7:177–182

Morgan D, Krueger RA (1993) When to use focusgroups and why. In: Successful Focus Groups:Advancing the state of the art. Sage, London

Morrell CJ, Spiby H, Stewart P, Walters S,Morgan A (2000) Costs and benefits ofcommunity postnatal support workers: arandomised controlled trial. Health TechnolAssess 4(6):1-73

Royal College of Medicine (2000) Life afterbirth: reflections on postnatal care. RoyalCollege of Medicine, London

Strauss A, Corbin J (1990) Basics of qualitativeresearch: Grounded theory procedures andtechniques. Sage, London

Twaddle S, Liao HX, Fyvie H (1993) AnEvaluation of postnatal CareIndividualised to the needs of Women.Midwifery 9: 140–154

United Kingdom Central Council (1998) TheMidwives Rules and Code of Practice.HMSO, London

POSTNATAL CARE


246� British Journal of Midwifery, May 2006, Vol 14, no 5

research�and�education

By Julie Wray

In the UK there exists clear policy identifying the need to involve and respond to patients and the public as part of National Health Service (NHS) strategies for ensuring

high quality services (DH, 1999). Being accountable to patients, by listening, consulting and involving them in the development of quality initiatives are defining features of cur-rent NHS policy. Within this context UK maternity care pol-icy is informed by a ‘women centred’ philosophy as recom-mended by ‘Changing Childbirth’ (DH, 1993). Involving women and their families in all aspects of the childbirth con-tinuum and service delivery is a core element of this approach. Postnatal care is no exception to this stance.

Previous studies have focused upon maternity care have identified that postnatal care appears to be under-valued and under-resourced and that many women are disillusioned and dissatisfied with the care they receive* (MacArthur et al, 1991; Bick and MacArthur, 1995, Bick et al. 2001). In a respected national survey mothers identified postnatal care as an area of concern; they made more negative comments about postna-

tal care than any other aspect of their maternity care (Audit Commission, 1997). Six years after the publication of this report, it became apparent that local mothers in the North West of England and a local user group continued to report concerns about postnatal care, in common with other published com-mentaries, literature and policy frameworks (Abbott et al, 1997; Marchant and Garcia, 2000; RCM, 2000). In response to local concerns an established maternity services liaison committee (chaired by a user member) and service managers, with a local user group, jointly developed a quality framework to improve postnatal care provision. It became apparent locally that there was a need to collect baseline information on women’s views about postnatal care. Assessing the quality of health care from the user’s perspective is complex (Wray, 2003) as what matters to a service user may well not be a concern or priority for the local health care provider (vanTeijlingen et al, 2003). However, this paper reports on the findings of a local baseline study that sought to involve local user groups on a small scale (Wray, 2002).

AimsThe study aimed to illuminate the views of local women who resided in two neighbouring urban locations in the North West region of England about the quality of care after birth. Overall this study was seeking to collect a detailed picture regarding the views of mothers of current services to an insight into the extent to which local services reflected postnatal policy.

ParticipantsThe participants were recently delivered mothers who lived in the commissioned neighbourhood (a city and urban town in the North West of England) and had given birth to a healthy baby during a 3 month period. In view of this being a survey a criteria for inclusion/exclusion was developed (see Table 1). This decision was pragmatic based on consensus opinion that this survey could be an inappropriate method for all mothers. In other words a more sensitive method would be best suited to include mothers with ill babies. A thousand women were identified as being potentially eligible to participate.

MethodA questionnaire was developed with the involvement of a local maternity care user group and the Maternity Services Liaison Committee, to reflect the local care provision. It combined open and closed questions based upon the user group’s experiences and the service provider’s service speci-fication. Mothers were asked about their experiences of the quality of ‘care after birth’ in hospital and at home. The ques-

abstractit�is�already�known�that�for�many�women�hospital�postnatal�care�is�the�least�satisfying�and�valued�part�of�their�maternity�care�provision�(audit�commission,�1997).�Furthermore,�it�continues�to�be�reported�that�research�in�the�area�of�postnatal�care�has�been�neglected�leading�to�an�insufficient�body�of�knowledge�and�evidence�to�support�postnatal�care�(Macarthur�et�al�1991;�Bick�et�al�2001;�Wray�2002).�there�are�major�issues�in�relation�to�the�content�and�organisation�of�postnatal�care,�yet�there�has�been�limited�revision�to�service�delivery,�which�is�struggling�to�cope�when�faced�with�a�shortage�of�midwives.�this�local�study�sought�to�involve�service�users,�notably�newly�delivered�mothers�and�an�established�users�group�in�a�participatory�manner�to�explore�mothers’�experiences�of�postnatal�care.�a�number�of�important�factors�emerged�that�provide�further�insights�into�what�matters�to�women�after�birth.�Postnatal�care�at�home�was�highly�regarded�and�valued�by�mothers�in�this�study,�but�concerns�continued�to�be�raised�about�postnatal�hospital�care.�Fundamental�components�of�service�delivery�in�hospital�such�as�cleanliness�and�hygiene,�visiting�arrangements,�noise,�rest�and�support�for�infant�feeding�and�baby�care�were�key�findings.�this�paper�presents�an�overview�of�the�study,�discussing�aspects�of�the�hospital�stay�and�reflections�on�the�study.

Julie�Wray�is�a�lecturer,�school�of�nursing,�university�of�salford.email:�[email protected]�

seeking�to�explore�what�matters�to�women�about�postnatal�care

248� British Journal of Midwifery, Month 2006, Vol 14, no 5


tionnaire was hand distributed by the community midwife on the 10th or 14th day as appropriate. A short pre-test pilot showed that this approach provided more responses than the postal method piloted. As a locally produced tool this baseline study was a pilot and assessment of its validity was considered at the end of the study. The women were asked to complete the questionnaire by 6weeks post-birth. Questionnaires were returned by post in a pre-paid envelope to the clinical audit office of one of the local hospitals.

EthicsThe local ethics committee was consulted and chair’s action determined that full approval was not required as this study was deemed to be an audit. The Chair considered the wom-en’s questionnaire and invitation letter in summary ‘ethical’. Guidelines for ethical practice were adhered to in line with research governance recommendations (DH 2001). The cov-ering letter outlined the study, pointing out the rights of indi-vidual’s regarding participation and assurances of anonymity and confidentiality. There were no follow up process as name and address were not recorded.

Data analysis The analysis framework was descriptive statistical analysis of the closed questions and thematic analysis of the open questions with the emphasis on the emergence of concepts

from data (Mason 2002). Towards the end of the study the Maternity Services Liaison Committee and local user group were consulted to produce action plans that informed the study recommendations.

Findings In total of 452 mothers participated in the survey resulting in a 42% response rate. Overall it was difficult to evaluate whether this was a satisfactory rate and this point will be returned to in the discussion section. However, for those mothers who did participate they were more likely to be aged between 25 and 34 years of age (61%), with 19% being aged less than 24 and 20% aged over 35 (see Table 2). Just under half (45%) were first time mothers and two thirds (66%) had a normal birth compared with 33% who had either a caesar-ean section, forceps or ventouse birth (1% gave no response to this question).

Figure 1 outlines the length of stay in hospital for all mothers involved in the survey. Over half of the mothers 59% stayed less than 2 days, with 32% staying less than 24 hours. A quarter (26%) mothers stayed either three or four days and 12% stayed between five and ten days. The survey did not collect the reasons for these variations.

Care at homeMothers were asked to rate the quality of the community midwives postnatal visits overall. In response to this question 98% of mothers rated the quality of care at home as being very good or good and only one mother said care had been very poor.

Table 3 outlines the percentage of mothers who felt that there was a need to improve on certain aspects of care at home. It can be seen that aspects suggested for improvement were; help with baby care and feeding and the way the midwife talked to some mothers. Mothers were given a chance to provide a nar-rative comment and just over a fifth (22%) did so. In relation to care at home there were very few negative comments given and where they were provided related to feeding support and improvements in communication. Specifically a point that was consistently mentioned by mothers was a desire to be consulted on the timing of home visits. The following contrasting com-

number�of�babies� � � � � � � � � � � � � ��totals

age�group� � � � � � � � � � � no�(n�=�452� 1st� 2nd� 3rd� 4th� 5th�� 6th� 7th� 8th� 10th� 11th� response� no� %

less than 18 years 7 7 1.4

18-20 years 19 7 26 5.8

21-24 years 32 14 3 2 51 11.3

25-29 years 52 36 8 5 4 106 23.5

30-34 years 67 68 16 9 2 4 1 2 169 37.4

35 and over 23 26 30 4 4 1 1 89 19.7

no response 1 1 1 1 4 0.9

total number 201 152 58 20 10 4 2 2 1 1 1 452

%� 44.5� 33.7� 12.8� 4.4� 2,2� 0.9� 0.4� 0.4� 0.2� 0.2� 0.2� � � 100

Table 2: The number of babies (parity) by age group

inclusion�criteria

nall mothers who had been transferred home together with their baby (birth weight over 2kg)

nCare was delivered by a midwife

nBoth mother and baby had been assessed ‘physically and mentally well’.

exclusion�criteria

nthe baby had died or was on sCBu or nursed in a children’s hospital or had been placed for adoption

nPostnatal care was delivered by a sCBu nurse/midwife or

nthe mother was assessed to be ‘physically or mentally ill’

Table 1. Participants’ inclusion/exclusion criteria



ments highlight this point:

‘It was very good the midwife always made an effort to come when it suited me and I was really happy and on the whole they were all very good and understanding’

‘One day the midwife said she’d be there in the morning we waited in all day and she did not turn up at all. I was never given an actual time for a visit’

A noticeable dimension not fully embraced was sexual activ-ity and contraceptive advice with 77% of mothers saying they had had some advice. The remaining quarter had no recall of having had any such advice. In addition, more information about local support groups and adequate time to talk with the midwife was mentioned and considered to be important. These mothers valued the time to talk to midwives and in an ideal world wanted more time with the midwife at home.

Care in hospitalIn contrast to care at home very different levels of satisfaction emerged regarding postnatal care in hospital irrespective of the hospital used and the length of stay. Numerical data and mothers comments illustrated that hospital care in relation to; the ward hygiene levels and cleanliness; security; noise levels to enable rest and recuperation; privacy and the need for peace and quiet; flexible visiting arrangements to accom-modate the needs of individual mothers and fathers; help and support with infant feeding and baby care; poor quality of the food; lack of support for mothers and finally concerns about the staffing levels needed attention. For the purpose of this paper infant feeding, baby care, visiting arrange-ments and rest have been selected for detailed consideration. Primarily due to these areas being a priority for the local user group and to some extent the service providers.

Visiting arrangements and restOverall the responses to the questions on visiting arrange-ments were full of contradictions. With 81% feeling that in terms of the length of visiting this was about right and 19% felt it was too short. Conversely in relation to flexibility of visiting 62% felt this was about right and 38% of mothers said that the times were not flexible enough. Mostly visit-ing problems focused on flexibility rather than length of visiting times. There were many narrative comments made by mothers on this topic, four distinct categories emerged as follows: 1. Flexibility of visiting for fathers, to allow for shift work, to

encourage the father in baby care and support the mother. 2. Accommodating large families and other children 3. Number of visitors 4. Timing of the visiting

Category one, related to improvements in flexibility to allow fathers or partners to access the ward and as such participate in baby care, over and above the designated visiting times. This was particularly explicit where shift work or working patterns was the issue. For some this needed to cover early morning and late night visiting. Category two, through up a real tension with no overall consensus across the data but it was evident that mostly mothers crave seeing their own family and chil-dren. Yet, at the same time there was a low tolerance to other mother’s visitors, as this annoyed some mother’s. This theme interlinked with the views expressed on the actual number of visitors (category three), as views here were couched in the notion that crowds of visitor’s resulted in noise and mayhem which then prevented rest. As an individual this was important but in terms of the whole ward in other words other mothers, had to be controlled. The final category paralleled with the sheer perplexity of accomplishing visiting times to suit ‘all of the people all of the time’. There was no correlation between satisfaction and hospital visiting arrangements that took a lassie fare approach versus a hospital that had a more set patterns and times applied to visiting.

These comments illustrate the diversity in views:

‘New Mums don’t really need lots of visitor’s just rest. Dads should be able to visit whenever though’

‘Constant interruptions from visitors, doctors, cleaners, paper sellers, bounty people etc. I just wanted some sleep’.

‘Only 2 hours a day for the family to come is not enough time’

‘Have two other children at school and visiting hours for partners only starting at 2pm we couldn’t have any real time together, this added more stress to the stay in hospital’

In essence visiting for some mothers can compound their opportunity to rest and recuperate. Although when asked specifically about rest 86% of mothers said ‘yes’ they had enough opportunity to rest whilst they were on the postnatal ward.

aspects�of�care�needing�improvement� Yes� no

having enough time to talk with the midwife 69 31

the way the midwife talked to you 14 86

help with baby care 16 84

help with infant feeding 15 85

Table 3. Aspects of postnatal care in the home that mothers felt needed to be improved

35.0

30.0

25.0

20.0

15.0

10.0

5.0

0.0

Per

cent

age

24 hours or less

2 days 3 days 4 days 5 to 10 days

14 days no response

Figure 1. Length of stay after birth

252� British Journal of Midwifery, Month 2006, Vol 14, no 5


Infant feedingMothers were asked several questions about infant feeding. In total 70% of mothers said they had intended to breast feed and of these 75% actually did breast feed. This means that for some unknown reason 25% did not even attempt to breast feed, despite stating an intention to do so. The total number of mothers in the survey who breast-fed was 54%; compared to 33% who bottle-fed and 13% who said that they mix fed their baby. These figures do not indicate how long mothers breast-fed for and whether they continued to breast-feed when they went home as this was not a remit of this survey.

Irrespective of feeding method mothers were asked if they were given enough help and support with feeding by day and at night. During the day 86% mothers felt that they were given enough help and support and this compared to 80% at night. The narrative comments for this question covered complimen-tary ones about help and support from staff such as:

‘The midwives were very supportive’

‘All staff were helpful and supportive with advice on feeding and I was given lots of information to read and had feed demonstrations’

However, for some mothers different views existed such as: ‘I felt it was a case of because I had other children, 11 years down the line I should remember, which should not be taken for granted’

‘I got the impression that because I chose to bottle-feed; feeding help and advice was overlooked’

‘I didn’t need advice as I told midwives I’d done it before’

‘Level of support was OK for me, but if it was a first mum then need more support at night’

Baby careQuestions about baby care were a concern of the user group at the outset and focused for the most part upon hygiene, skin care and handling of the baby. Mothers were asked whether they were shown how to perform particular activities such as bathing, nappy changing, care for the baby’s umbilical cord and given advice on infant sleeping positions. In addition, mothers were asked to indicate if there were any other skills they would have liked to have been shown.

Table 4 illustrates that not all mothers were shown how to undertake particular activities. For example about two thirds were not shown how to change their baby’s nappy or how to top and tail (a parochial term for cleaning the baby’s face and but-tocks). A third 34% of all mothers was not shown how to bath their baby. However, in relation to nappy changing 50% of the first time mothers had not been shown how to do this.

Knowledge about essential baby care and being able to carry out fundamental aspects of baby care is important to parents. Midwives in particular play a major role in enabling parents to adapt to parenthood and should actively assist new

parents in their adjustment (RCM 1999). A possible limita-tion of the questions asked in this part of the survey could have been the fact that there was no indication about choice i.e. if the mother (or partner) had had an offer to be shown baby care and then declined. However, this said 18% of mothers made specific suggestions about baby care activities they desired and these included: n Wind, ‘tips’ and dealing with the ‘windy baby’n Dressing the baby, advice about clothing and blanketsn Handling and holding the baby including putting the baby

‘correctly in the cot’n Dealing with a crying babyn Baby massagen More help with breast feeding and advice about feed

preparation

Discussion Asking women about their own experiences of maternity care is a noble and reasonable undertaking and provides useful information for service providers. In relation to postnatal care we already know that many women feel less satisfied with this aspect of the childbirth continuum in comparison to antenatal, labour and birth care provision (Audit Commission 1997). In addition, in a recent study Ockleford et al (2004) found new mothers experiencing a mismatch between expec-tation and the service provided. Ockleford et al found that mothers were eager to go home early due to a perceived lack of support from midwives on the postnatal ward.

In bringing together these findings it can be seen that what matters to women is a positive hospital ward experience wherever possible. Details on visiting arrangements, infant feeding and baby care are highlighted in this paper as key aspects to be con-sidered in attempting to improve the overall hospital care experi-ence. Although tensions and challenges clearly exist in trying to provide the ideal visiting times and arrangements, that will suite all mothers and their families. Within the limits of this study we found no correlation between visiting arrangements and rest/recuperation, as such it cannot be assumed that they are related. However, where a defined visiting pattern existed, service man-agers hinged their explanations for such a protocol on rest and recuperation of mothers. The challenge of communal living on a postnatal ward could explain the low tolerance levels towards other people’s visitors and the desire for some control over this. Burden (1998) found that the use of bed curtains can provide mothers with some control over their privacy and opportunity to recuperate. In part this practice can act favourably during visit-ing and replicate a single room to secure more privacy. However, curtains do not exclude noise or provide total privacy.

Baby�care�activity� � Yes�� %

Bathing 66

Changing nappies 34

top and tail 34

Cord care 69

sleep positions 70

Table 4. Percentage of mothers shown aspects of baby care in hospital



It can be seen that contrasting findings emerged from these mother’s views on their postnatal care at home. On the one hand this may seem obvious as broadly speaking home is more comfortable and conducive to family life and recovery from birth. Some areas were flagged up as requiring attention, tim-ing of midwives visit to the home, advice on sexual activity and contraception and more time with the midwife. This latter find-ing could be interpreted as highly positive towards community based midwifery in that it illustrates the value mothers’ place upon talking to a midwife. However, there is no direct link and correlation between talking with the midwife and quality of care. So this finding should be treated with caution.

Consulting service usersImportantly this study asked women about their postnatal experiences and care packages it embraced the philosophy of current UK policy. Furthermore, it involved a user group in the process albeit on a small scale as an aspiration of the study was to be inclusive and ‘women centred’. The user group and maternity services liaison committee did have an involvement in constructing the survey, commenting on the findings and the final report. Together they acted as a reference point for the study as suggested by Anderson and Podkolinski (2000). Action plans were drawn up by the respective hospitals to address the key findings and efforts to improve hospital care have been undertaken. Future evaluations are planned and once completed the findings will be compared to assess where improvements have occurred.

Reflecting upon the response rate this was disappoint-ing, in part could be a reflection of the distribution process. Nonetheless life can be hectic after having had a baby and the notion of completing a questionnaire could be unappealing (a further paper is being developed on this aspect). For this reason a follow-up letter and questionnaire was avoided. Research is not a sterile and clean endeavour, unintended events and find-ings emerge especially when seeking to hear the voice of the user (Anderson and Podkolinski 2000; vanTeijlingen et al 2003). Service providers need to consider the uncertainties and short-falls of performing survey work with newly delivered mothers’ as this may not be the most appropriate method.

Considerations for service providersUltimately though the postnatal period is characteristically regarded as the end point or an ending of the childbirth con-tinuum, but in reality it is the beginning, in fact the start of a journey. During this time women should be made to feel impor-tant and special; they need to feel confident and supported with their adaptation to parenting. What women think and feel about care provision has to be valued and considered by service

providers (Bick et al, 2001, Wray, 2003). There is no escaping the fact that the length of postnatal hospital stay has declined dramatically in the past thirty years (DH, 1997). As a result the organization of hospital postnatal care relies on and supports the quick throughput of women. The context and culture of the hospital ward environment needs to be better understood and conductive to its intended purpose. The pending NICE guideline on postnatal care and the newborn could provide a much needed evidence base to address and support postnatal care in the future. Optimistically it is hoped that the discourse of ‘Cinderella’ will cease to prevail within maternity care.

ConclusionA final thought concerning postnatal care debates is the visibil-ity and inclusion of midwives. The views of midwives matter too. For example how midwives understand their role and view contemporary postnatal care needs to be captured and taken into account. On this note Cattrell et al (2005) have under-taken a small scale qualitative study exploring midwives percep-tions of postnatal care in an area of the North West of England. What they found was that priorities in postnatal care, societal influences and job satisfaction mattered to midwives. With the rapid turnover of mothers and babies on postnatal wards it is maybe no surprise that midwives feel the impact too. BJM

Acknowledgements Thanks to all the mothers who took part in this study, the local user group; the Maternity Services Liaison Committee; the PCT who funded the study and colleagues for their support. Key people are commended for their support, also thanks to Dr Lisa Davies for comments on draft papers.

Abbott H, Bick DE, MacArthur C (1997) Health after birth. In: Henderson C, Jones K, eds. Essential Midwifery. Mosby, LondonAnderson T, Podkolinski J (2000) Reflections on midwifery care in the postnatal period. In: Alexander J, Roth C, Levy V, eds. Midwifery practice: core topics three. Macmillan, Basingstoke: 1-18Audit Commission (1997) First Class Delivery. Improving Maternity Services in England and Wales. Audit Commission Publications, AbingdonBick DE, MacArthur C (1995) The extent, severity and effect of health prob-lems after childbirth. British Journal of Midwifery 3: 27–31Bick D, Mac Arthur C, Knowles H, Winter H (2001) Postnatal Care Guidelines for Management. Churchill Livingstone, Edinburgh Burden B (1998) Privacy of help? The use of curtain positioning strategies within the maternity ward environment as a means of achieving and maintaining privacy, or as a form of signalling to peers and professionals in an attempt to seek information on support. J Adv Nurs 27: 15-23.Cattrell R, Lavender T, Wallymahmed A, Kingdon C, Riley J (2005) Postnatal care: what matters to midwives. British Journal of Midwifery 13: 206-13Department of Health (1993) Changing Childbirth. The report of the expert maternity group. The Stationary Office, LondonDepartment of Health (1997) NHS Maternity Statistics, England: 1989–90 to 1994–95. Statistical Bulletin 1997/28. The Stationary Office, LondonDepartment of Health (1999) Modernising Health and Social Services: National Priorities Guidance 2000/01-2002/03. DH, LondonDepartment of Health (2001) Research Governance Framework for Health and Social Care. DH, LondonMarchant S, Garcia J (2000) The need to talk after birth: evaluating new serv-ices. In: Alexander J, Roth C, and Levy V, eds. Midwifery Practice: Core topics 3. Macmillan Press Ltd, London Mason J (2002) Qualitative Researching. 2nd edn. Sage Publications, London. MacArthur C, Lewis M, Knox EG (1991) Health After Childbirth. TSO, [email protected] Ockleford EM, Berryman JC, Hsu R (2004) Postnatal care: what new mothers say. British Journal of Midwifery 12: 166-70Royal College of Midwives (2000) Midwifery Practice in the Postnatal Period - Recommendations for practice. RCM, LondonvanTeijlingen, ER, Hundley V, Rennie A, Graham W, Fitzmaurice A (2003) Maternity satisfaction studies and their limitations: “what is, must still be best”. Birth 30: 75-82.Wray J (2002) Care after birth: Views of Salford and Trafford mothers – a baseline evaluation. Main Report. The University of Salford, SalfordWray J (2003) Powerful sharing? Creating effective user groups. Pract Midwife 6: 18-19

Key�PointsnWomen’s�views�of�their�hospital�postnatal�care�continue�to�

highlight�concerns.�nWomen’s�views�of�postnatal�care�at�home�significantly�

surpassed�the�hospital�ward�experience.nseeking�the�views�of�new�mothers�is�worthwhile,�alongside�

a��user�group,�so�that�care�provision�can�be�evaluated�and�reconfigured�where�appropriate.

In response to feedback from women andin order to improve the care of womenwho experience birth by caesarean sec-

tion at a central London teaching hospital,registered general nurses (RGNs) and nurs-ery nurses (NNs) were recruited to supportmidwives in caring for women postnatally.The nurses would focus on women’s specificnursing needs following surgery and thenursery nurses would help women care fortheir babies. It was intended that this wouldfree up more time for midwives to spend giving specific midwifery care.

BackgroundTo date, work on satisfaction in postnatalcare has tended to cover women who haveexperienced all modes of birth rather thanfocus solely on those who have experiencedcaesarean sections (Kenny et al, 1993;Proctor, 1999; Waldenstrom et al, 2000; vanTeijlingen et al, 2003).

Women who have caesarean sections haveadditional needs caring for their babies whilerecovering from the impact of major surgery

(National Institute of Clinical Excellence(NICE), 2004; Hillan, 2000; Royal College ofMidwives, 2000; Davies, 1982).

The employment of RGNs and NNs cameabout in response to feedback from somewomen who had had caesarean sections.Two registered nurses were recruited initially to provide specific postoperativecare (e.g. vital sign measurement, adminis-tration of pain relief and to care for awoman’s abdominal wound and urinarycatheter) and four nursery nurses. Thenursery nurses helped women to feed andcare for their babies.

Both the registered nurses and the nurs-ery nurses worked in partnership with themidwives and health care assistants andreported to the senior midwife in charge ofthe postnatal wards at night. Meetings wereheld to inform midwives and health careassistants of the staffing model change.Both these staff groups seemed to managethis change extremely quickly and came torecognize the value of having the help oftheir new professional colleagues.

AimsThe study set out to evaluate a change inpractice. It did this by comparing women’sviews of care and the care they receivedbefore and after general and nursery nurs-es were introduced into postnatal wardsand by a casenote review.

Methods Postal questionnaires were used to obtain theviews of women who had experienced birthby caesarean section before and after thenurses were introduced. This was modelledon a questionnaire used by Sandall et al toanalyse views and experiences of maternitycare (Sandall, Kelly and Fitzgerald, 2002) andadapted for use among women who had hadcaesarean sections. Following consultation

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Postnatal caesarean care:evaluating the skill mixBy Jackie Baxter and Alison Macfarlane

ABSTRACTThe government, in its plan for reforms in the NHS, recognizes theimportance of nurses and midwives undertaking new roles and breakingdown old demarcations (Department of Health, 2000). In response tofeedback from women and in order to provide safe and effective care forwomen who experience birth by caesarean section at a central Londonteaching hospital it was decided registered general nurses (RGNs) andnursery nurses (NNs) were recruited to provide support for midwives incaring for women postnatally. The nurses would support the women withtheir specific nursing needs while they recovered from surgery and nurserynurses would help women care for their babies. The aim was to free upmore time for midwives to spend giving specific midwifery care. A postalquestionnaire was sent to women who gave birth by caesarean before andafter the nurses and nursery nurses were recruited. The introduction ofthese new roles appears to have improved care for women who experiencedbirth by caesarean section.

Jackie Baxter is aresearch anddevelopment midwife atUniversity CollegeLondon Hospitals andAlison Macfarlane is aprofessor of perinatalhealth, Department ofMidwifery, City University

This article was acceptedfor publication on 18January 2005

378 BRITISH JOURNAL OF MIDWIFERY, JUNE 2005, VOL 13, NO 6

with service staff and piloting with women,after its adaptation, on the postnatal wards,further amendments were made.

The women’s casenotes were alsoreviewed to determine the frequency of clin-ical observations and care interventions suchas blood pressure measurements, adminis-tration of pain relief, frequency of vital signmeasurements, administration of drugs andobservation of caesarean section wound.

Questionnaires were sent to all womenwho had caesarean sections and live healthybabies born during a three month periodprior to and after the introduction of the nurs-es and nursery nurses. The accompanyingletter invited women, for whom English wasnot their first language, to ring the maininvestigator and an interpreter was arranged.In these circumstances interviews using thequestionnaire were either conducted overthe telephone or at the hospital where theresearch was carried out depending on thewoman’s preference. The questionnaireswere sent to the women between five and 18weeks postnatally. Reminder letters weresent two weeks after the first letter was sent.

The data from the questionnaires andcasenotes were analyzed using the StatisticalPackage for the Social Sciences version 11.5(SPSS). Differences between groups werecompared using Chi-squared tests. Approvalwas obtained from the local NHS TrustResearch Ethics Committee. A group ofexpert practitioners formed an advisorygroup for the project.

Sample sizeWhen planning the study it was important towork out the number of participants neces-sary to ensure valid findings. An earlierpatient satisfaction survey indicated that 25%of all women were dissatisfied with postnatalservices. A sample size of 125 in each armwould have at least 80% power to detect a fallin the dissatisfaction rate from 25% beforethe change to 10% after the change. Thisequates to sending questionnaires to womenwho had sections for 3 months in both legswith a response rate of 65%.

ResultsThe study set out to compare the situationbefore (February 2003 to April 2003) and

after (September 2003 to December 2003)when registered general and nursery nurseswere introduced into the postnatal wards.

The response rates for the questionnaireswere 68% (phase one) which included thewomen who received care before new staffwere introduced and 65% (phase two), whichconsisted of a similar group of women whoexperienced care after the nursing staff were recruited. A profile of the study participants can be seen overleaf in Table 1. Characteristics such as age and eth-nicity were similar in both phases. Detailsavailable in Appendix 1 to the article atwww.intermid.co.uk

Care in the postnatal wardWomen’s satisfaction with care during boththe day and night times improved followingthe introduction of the nurses and nurserynurses (Table 2) (page 382). 53% of womenin phase two described their care during theday as excellent or very good compared with35% in phase one. Only 12% of women inphase two reported care as being poor orvery poor compared with 33% in phase one.

Differences were even greater at night. Inphase two, 59% of women described the carethey received on the postnatal ward at nightas being excellent or very good comparedwith 28% in phase one. Also, far fewer

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BRITISH JOURNAL OF MIDWIFERY, JUNE 2005, VOL 13, NO 6 379

Physical support

Table 4 (page 383) illustrates the numbersof women in both phases receiving physicalsupport by the staff on the postnatal wards.

i) Pain reliefIn each phase very similar proportionsreported receiving regular medication – 88%(phase 1) and 85% (phase 2) of women.When requested the women in phase two didnot wait so long as those in phase one toreceive pain relief. 65% of women in phaseone waited for more than 15 minutes com-pared with 34% in phase two. Interestingly,following the introduction of the nurses morewomen missed doses of pain relief. 34% ofwomen in phase two were found to havemissed three or more doses of analgesiacompared with only 21% in phase one.

ii) Wound careIn phase two 81% of women remember amember of staff inspecting their woundduring the first 24 hours compared with71% in phase one, but this was no differentthan would be expected by chance.Information in the casenotes supports this.Among 95% of women in phase two and91% in phase one there were reports in thecasenotes that staff regularly observed the wound.

iii) Personal hygieneMore women in phase two said theyreceived help with personal hygiene, suchas assistance to wash in bed or help out tothe bathroom. In phase two, 59% reportedthis compared with 44% in phase one.

iv) Catheter careIn phase two, 77% of women rememberedstaff observing their urinary catheters. Thiswas significantly higher than in phase one.High incidences of urine bags beingobserved were found in the casenotesreviews in both phases. There were 99.5%in phase two compared with 96% in phaseone. In addition, more women were foundto have their fluid output recorded following the introduction of the nurses.

v) Physical observationsThe number of times women had their vitalsigns measured also increased. According to

women described care as poor or very poor.In phase two, 22% said care was poor or verypoor compared with 47% in phase one.

All participants were asked to tick a list of possible necessary improvements to the service. During phase one staff availabilityand care following birth by caesarean sectionwere among the most commonly ticked.Fewer women commented about theseissues in phase two (Table 2) (page 382).

The participants were also invited to giveany other general comments about theirpostnatal care. Lack of care, too few staff andgeneral compliments were the most commonly cited points for women in bothphases. Lack of care and too few staff werereported much less often among the partici-pants in phase two and there were more positive comments about individual staff (compliments) in phase two.

Practical support on thepostnatal wardTable 3 (page 383) shows that women inphase two were better orientated to the ward.63% of women in phase two (49% in phaseone) said they received introductions fromstaff. In addition, 38% of women in phase tworeported being orientated to the postnatalward immediately following transfer fromthe delivery suite compared with 25% ofwomen in phase one. More women in phasetwo (22%) were told about meal times in thepostnatal ward compared with 13% in phaseone, but this difference was not significant.


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Phase one Phase two

Caesareans undertaken 225 227

Less:

Exclusions (e.g. 10 10

stillbirth, neonatal death)

Questionnaires sent/casenotes requested 215 217

Questionnaires returned 147* 143**

Less:

Exclusions 1 1

Casenotes not available 8 20

Questionnaires analyzed 146 142Casenotes analyzed 206 196

* (response rate 68%)** (response rate 65%)

Table 1. Profile of study participants

the review of the casenotes 81% of womenhad their vital signs measured three or moretimes during the first 24 hours when theywere back on the postnatal ward duringphase two compared with 59% in phase one.

Help and adviceTable 5 (page 384) shows the amount of helpand advice given to women. There were sta-tistically significant differences in the pro-portion of women who received help andadvice with feeding the baby, caring for thebaby and for their own health needs betweenthe two phases. Table 3 (page 383) showsthat in phase two 73% of women reportedreceiving support with feeding either alwaysor sometimes which was significantly higherthan the 48% of women in phase one. Table5 (page 385) shows that women perceivedstaff as supportive and caring in both phases.This applied to 88% of women in phase twoand 71% in phase one.

DiscussionNational clinical guidelines (NICE, 2004)state that women require additional supportfollowing birth by caesarean section, partic-ularly in relation to breastfeeding. Thisstudy has found an increase in satisfactionwith postnatal care among women follow-ing the introduction of nurses and nurserynurses into the skill mix of a postnatal ward team.

The introduction of these new rolesappears to have improved care for womenwho experienced birth by caesarean section. The findings of the second part ofthis evaluation show a significant improve-ment in the overall satisfaction with postna-tal care experienced by women who hadcaesarean sections. In addition there weresignificant differences in the proportions ofwomen who received support with feedingin phase two.

The physical aspects of care do not seem tohave been compromised following the intro-duction of the new roles. In fact there wereimprovements. When requested by women,pain relief was administered significantlymore quickly, measurements of vital signswere conducted more frequently, womenreceived more help with personal hygieneand fluid balance was better recorded.

Staffing levels are crucial to providingquality care. A paper by Ockleford et al(2004) showed that women perceived thereto be a shortage of staff on the postnatalwards. Women in the present study alsoreported seeing too few staff as well asexperiencing a general lack of care. Theyemphasized the need for more staff, partic-ularly before the introduction of the nursingstaff. After the change was made fewerrespondents reported lack of care andwomen perceived staff as being less busy.

Despite expressions of dissatisfaction andconcern about lack of care being more evi-dent during phase one, staff were reportedby women in both phases to be supportiveand caring. This finding suggests that stafftry hard to provide support for women andconcurs with a research survey by DrRegina Coppen, Consumer views of materni-ty care in Mid Surrey, which was presentedat a conference at the Bradbury Centre,Surrey in 1990. This latter work revealedthat 84% of mothers found postnatal wardstaff to be helpful and caring.

The study is set against the nationalbackground of reducing the caesareansection rate. It is interesting that wherewomen commented, a considerable num-ber in both phases were content that hav-ing a caesarean section was the rightthing to do. Indeed a fifth of women inboth phases admitted to being eitherpleased or very pleased about having hada caesarean. The National Sentinel cae-sarean section audit (Thomas andParanjothy, 2001) found a large majority ofwomen agreeing to want a birth experience that is safest for the baby.

In 1992, 20% of women did not know whythey had needed to have a caesarean section (Hillan, 1992). The present studyfound that the indication given in thecasenote review for caesarean section bythe obstetrician does not always match thereason understood by the woman for hav-ing needed a caesarean section in about aquarter of cases.

Despite efforts to involve women more incare decisions and advances in the level ofinformation being given since theChanging Childbirth report (DH, 1993) asimilar proportion of women still do notknow the exact reason for having their caesarean section.

BREASTFEEDING DATA COLLECTION


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Conclusions

This study has found that before the nursing staff were introduced, manywomen who had given birth by caesareansection perceived postnatal care to be lacking. This includes requiring more helpwith feeding and caring for their babies,waiting for long periods before receivingpain relief and failing to receive help withpersonal hygiene. After introducing thenursing staff there was a significantimprovement in the overall satisfactionwith postnatal care as experienced bywomen who had caesareans. Consequentlythe introduction of new roles in postnatalcare in the study hospital appears to haveimproved care for women who experiencedbirth by caesarean section.

Since the completion of the pilot schemethe number of nurses and the nursery nurses has increased and their skills arenow being used during the day as well as atnight. The findings of this work have been

disseminated in the unit and used to informdecisions, including those about whether to further develop these roles in other areas ofpostnatal care i.e. to support women andbabies following vaginal birth.

Recommendations for futurepracticeEducation and training programmes inpostnatal care issues should be developedfor staff who are new to practice in thisarea. It is essential when employing staff toundertake new roles that they are adequately trained to carry this out.

General awareness of the new roles byother staff is also essential. It is imperativethat other staff are also familiar with thisnew role to avoid confusion which couldlead to frustration of staff and have animpact on the care of women.

This study has concentrated on the viewsof the user of the service, which is essentialwith the evaluation of a new service.

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Numbers Percentages Chi square

Phase one Phase two Total Phase one Phase two Total test result

Rest and sleep

Had enough rest and sleep 42 77 119

Numbers answering the question 140 140 280 30 55 43 P=0.000

Staff were too busy

Staff were often too busy 91 61 152


Care in postnatal ward during the day

Excellent/good 50 74 124 35 53 44

Average 46 38 84 32 27 30

Poor/very poor 48 27 75 33 19 27 P=0.01

Numbers answering the question 144 139 283

Care in postnatal ward during the night

Excellent/good 40 82 122 28 59 43

Average 37 26 63 26 19 22

Poor/very poor 68 30 98 47 22 35 P=0.000


General comments

Improvements needed:

Staff availability 111 80 191 76 56 66

Care following caesarean birth 86 56 142 59 39 49

Total questionnaires 146 142 288

Table 2. Overall satisfaction

BJM

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Numbers Percentages receiving help Chi square


Received introduction on transfer to ward 71 90 161 49 63 56 P=0.02


Orientated to toilets and bathrooms 35 51 86 25 38 31 P=0.07


Informed about arrangements for meals 18 30 48 13 22 17 P=0.12


Received support with feeding (always/sometimes) 63 83 146 48 73 60 P=0.000


Table 3. Practical support given by staff on postnatal ward

Numbers Percentages receiving support Chi square


Pain relief

Received regular medication 121 125 246


Waited longer than 15 min. for pain relief 53 27 80


3 or more doses missed according to casenote review 40 60 100

Number of casenotes reviewed 190 177 367 21 34 27 P=0.000

Wound care

Wound inspected during first 24 hrs 103 114 217


Wound inspected according to casenotes 180 184 364


Personal hygiene

Received help with personal hygiene 63 82 145


Catheter care

Staff checked catheter and urine bag 84 108 192


Urine bag observed according to casenotes 187 185 372


Fluid output recorded regularly 5 19 24


Vital sign measurements

Measured 3 or more times in first 24 hrs 112 147 259


Table 4. Physical support given by staff on postnatal wards

of changing roles on women and health pro-fessionals. NHS Executive, London

Hillan E (2000) The aftermath of caesareandelivery. MIDIRS Midwif Digest 10(1):70–72

Kenny P, King MT, Cameron S, Shiell A(1993) Satisfaction with postnatal care –the choice of home or hospital. Midwifery9: 146–53

National Institute of Clinical Excellence(2004) Caesarean section Clinical Guideline13 National Institute of Clinical Excellence,London

Ockleford EM, Berryman JC, Hsu R (2004)Postnatal care: what new mothers say. Br JMidwifery 12(3): 166–71

Proctor S (1999) Women’s reactions to theirexperience of maternity care. Br JMidwifery 7 (8) 492–498

Royal College of Midwives (2000) Midwiferypractice in the postnatal period. RoyalCollege of Midwives, London

Thomas J, Paranjothy S (2001) The NationalSentinel caesarean section audit report.Royal College of Obstetricians andGynaecologists Press, London

van Teijliingen ER, Hundley V. Rennie A,Graham W, Fitzmaurice A (2003) Maternitysatisfaction studies and their limitations:what is, must still be best. Birth 30(2): 75–82

Waldenstrom U, Brown S, McLachlan H, ForsterD, Brennecke S (2000) Does team midwifecare increase satisfaction with antenatal,intrapartum, and postpartum care? A ran-domized controlled trial. Birth 27(3) 156–67

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KEY POINTS

■ Women giving birth bycaesarean sectionrequire more supportpostnatally.

■ A pilot scheme aimed toimprove care by studyingthe addition of nurses andnursery nurses to a ward.

■ A postal questionnairewas sent to two samplesof women who gave birthby caesarean, before andafter the staff wererecruited.

■ The introduction of thesenew roles appears tohave improved care forwomen who experiencedbirth by caesarean

Numbers Percentages receiving help Chi square


Received help and advice with/about:

Feeding the baby 46 74 120Numbers answering the question 141 137 278 33 54 43 P=0.001

Care of the baby 27 49 76Numbers answering the question 139 134 273 19 37 28 P=0.006

Health of the baby 53 53 106Numbers answering the question 141 134 275 38 40 39

(woman's) Own health needs 52 76 128Numbers answering the question 141 137 278 37 55 46 P=0.005

Received conflicting advice 70 63 133Numbers answering the question 141 136 277 50 46 48

Staff were supportive and caring (always/sometimes) 101 123 224Numbers answering the question 143 140 283 71 88 79 P=0.000

Table 5. Help and advice given by staff on postnatal ward

BJM

Further study is required from the perspective of staff. Qualitative methodswould be of interest to glean valuableinsight into the nature of the different roleswithin the maternity setting.

The study is based on the experience ofone London teaching hospital. It is a tertiaryreferral centre with a consequent high cae-sarean section rate. Further research isneeded to see if the findings are similarelsewhere. It is important to speak with allwomen following birth in order to help themmake future childbirth decisions. Womenneed to understand the reasons why theyhave had caesarean sections.

The authors would like to thank all thewomen involved in this study. They wouldalso like to thank the staff at both the hospi-tal where the research took place and at CityUniversity for their cooperation and support.

Davies K (1982) A conflict of roles forum:motherhood. Nurs Mirror 82(7): iii–iv

Department of Health (1993) ChangingChildbirth. Department of Health, London

Department of Health (2000) The NHS Plan.Department of Health, London

Fitzgerald L, Sandall J,Harvey J, Kelly B,(2002) Delivering maternity care: the impact


research and education

support for infant feeding: mothers’ perceptionsBy Patricia A Cairney, Elizabeth M Alder and Rosaline S Barbour

There has been much interest in infant feeding since 1981 (World Health Organization (WHO), 1981) and one consistent strand has been the promotion of

breastfeeding. It is well recognized that breastfeeding has the potential to reduce infant mortality and morbidity in devel-oping countries, but there has been difficulty in achieving the WHO aims—particularly in light of the commercial benefits to be gained through the promotion of artificial (bottle) feed-ing (WHO/UNICEF, 1981; WHO/UNICEF, 1997). There has been a significant increase in promotion of breastfeeding by health professionals since the early 1990s, and this forms an important element of the Baby Friendly Hospital Initiative (WHO/UNICEF, 1989) which seeks to maximize breastfeed-ing uptake and maintenance.

This emphasis has had considerable success in some parts of the UK in increasing breastfeeding rates and duration. Scottish figures for exclusive breastfeeding at six weeks were not available in the Infant Feeding 2000 survey (Hamlyn et al, 2002), but figures for the whole of the UK in 2000 indi-cated that only 25% of infants were exclusively breastfed by the age of seven weeks. Hence, 75% of women were giving some artificial milk to their infants by seven weeks postnatally while, by five months of age, 84% of infants were being given some formula feeds (Hamlyn et al, 2002). This suggests that a considerable number of women in the UK need information

about bottle-feeding and, arguably, health professionals are in an ideal position to provide expertise in these matters.

In a study of information on bottle-feeding given to moth-ers, breastfeeding mothers reported receiving less information than did bottle-feeding mothers. However, only 40% of the bottle-feeding mothers reported that they received any bottle-feeding information from professionals antenatally, and only 65% in the first month postnatally (Cairney and Alder, 2001). In addition, breast and bottle-feeding mothers perceived different amounts of infant feeding support from health professionals. The findings related to information giv-ing were also reported by Lee and Furedi (2005) who found similar situations in the south-east of England.

The care pathway for mothers and newborn infants in the UK varies only slightly depending on local circumstances. In the Scottish regions studied it is usual for midwives (either Hospital or Community) to undertake all the pre-natal and intrapartum care in a normal pregnancy and delivery. Care of mother and infant remains with the midwives until approximately ten days postnatally when, usually, ongoing monitoring of the infant becomes the remit of the health visi-tor (Scottish Executive (SE), 2002). This paper explores, at one month postnatally, mothers’ perceptions of the behaviour of health professionals, and their attitudes towards breast and bottle-feeding mothers in Eastern Scotland.

MethodThe questionnaires sent at one month postnatally formed part of a wider study, involving one antenatal and three postnatal questionnaires. All women (age 16 and over) in the geographi-cal area, who were expecting their first baby and having an uncomplicated pregnancy at 34 weeks gestation, were recruit-ed. Approval for the study had been granted by the two regional research ethics committees. Piloting of the questionnaires was carried out for face validity, and no alterations to the statements were deemed necessary following this. Women were recruited from community midwife caseloads, until 500 women had returned the antenatal questionnaire, thus indicating they were taking part in the study (54% recruitment rate). The first of three postnatal questionnaires was sent at one month postna-tally and there was a 78% response (n=392). Six statements about how women perceived the behaviour and attitudes of health professionals had been developed by the researchers (Table 1) to test the research question, and they were scored on a five point Likert scale. The statements fell into two categories: general statements relating to how women think health profes-sionals behave towards new mothers, and women’s views of how they think breast and bottle-feeding mothers are perceived by health professionals.

Patricia cairney is Lecturer and rosaline Barbour is Professor of health and social care, school of nursing and Midwifery, university of dundee, scotland and elizabeth alder is research Professor, napier university, edinburgh, scotland.

abstractthis study was designed to elicit how first-time mothers felt about the amount and type of support they received from health professionals about infant feeding.

the study took place in eastern scotland. two hundred and ninety-seven women, of 23 years and over, expecting their first baby and experiencing a pregnancy free of complications, were included in this report.

six statements about perceived behaviour and the attitudes of different health professionals were scored on a Likert scale. in this sample new mothers perceived midwives as giving less support than doctors or health visitors, and they were seen as more likely to favour breastfeeding women. additionally, women who were giving some or exclusive formula feeds were more likely at one month to perceive midwives in this way.

694 British Journal of Midwifery, deceMBer 2006, Vol 14, no 12


Women were categorized into two groups: either exclu-sively breastfeeding, or offering some formula feeds, i.e. bot-tle-feeding, at one month postpartum. In the latter category some women may have been giving few formula feeds but would still benefit from advice on formula feeding. Women rated the statements for all four health professional groups

(hospital midwives, community midwives, health visitors and family doctors) and the results were compared using the Wilcoxon Signed Ranks test. Perceptions of the two feeding groups were compared using the Mann Whitney U test. In considering these results means, rather than medians, of the Likert scale scores are displayed in Table 4 to indicate which group has the higher level since, in many cases, the median is the same for both breast and bottle-feeding women.

To reduce the risk of multiple significances inappropriately suggesting differences, p<0.01 was selected as demonstrating a significant difference between the two groups.

FindingsDeprivation categories, which provided an estimation of socio-economic variation (McLoone, 1995) and experiences of higher education in the study population were similar to those of the women who had been sent the initial question-naire, i.e. all first time mothers in the two adjacent geo-graphical regions. These demonstrated normal distributions. However, there was a bipolar distribution of age evident both in the population as a whole and in those responding to the questionnaire with groups dividing into a young group (mode 18 years), and an older group (mode 28 years). The dividing point between these two populations was taken as 22 years, since this was the age with the fewest women between the two modes. This recognizes the very different demographic characteristics of younger women in comparison to older women in the population (Whitehead, 2001). Compared to the population in the study area, women under 23 years of age were under-represented in replies to the questionnaires, as has been identified elsewhere (Shepherd et al, 1998) and so in this paper, only those women of 23 years of age and over have been considered.

Comparison of perceived behaviour of health professionals (Table 2)No difference was found between the women’s perceptions of hospital midwives and community midwives or hospital midwives and health visitors, on whether they were seen as giving enough information antenatally about infant feeding to women. Community midwives were more likely than health visitors to be seen as giving enough information about infant feeding antenatally (p=0.004).

All but two of the women delivered in hospital and the usual hospital stay was two to four days at that time, mean-ing that they had substantial contact with hospital midwives. However, hospital midwives were less likely than were com-munity midwives (p=0.001) or health visitors (p<0.001) to be seen as giving enough help or spending enough time with new mothers in the postnatal period. Women were less likely to think family doctors were supportive compared to how they viewed other health professionals’ input (p<0.001).

Comparison of perceived attitudes of health professionals (Table 3)Both breast and bottle-feeding mothers considered that hospi-tal midwives spent more time with breastfeeding mothers than with bottle-feeding mothers (p<0.001) and hospital midwives were characterized as thinking that they had a bigger role to

1. this person gives enough information about infant feeding to women before baby is born.

2. this person gives enough help to new mothers with infant feeding.

3. this person spends enough time with new mothers.

4. this person spends more time helping mothers who are breastfeeding than who are bottle-feeding.

5. this person thinks breastfeeding mothers are more important than bottle-feeding mothers.

6. this person expects mothers to breastfeed.

(likert scale score: 1=strongly disagree, 5=strongly agree)

Table 1. Statements rated by women

statement health practitioners significant findings

this person gives community midwife: enough information vs. hospital midwife n.s. about infant feeding vs. health visitor Z=2.8, p=0.004, cm>hv to women before vs. family doctor Z=10.7, p<0.001, cm>fd baby is born hospital midwife: (n=283). vs. health visitor n.s. vs. family doctor Z=7.59, p<0.001, hm>fd health visitor: vs. family doctor Z=9.11, p<0.001, hv>fd

this person gives community midwife: enough help to new vs. hospital midwife Z=3.40, p=0.001, cm>hm mothers with infant vs. health visitor n.s. feeding (n=283) vs. family doctor Z=12.2, p<0.001, cm>fd hospital midwife: vs. health visitor Z=3.88, p<0.001, hv>hm vs. family doctor Z=10.1, p<0.001, hm>fd health visitor: vs. family doctor Z=12.6, p<0.001, hv>fd

this person spends community midwife: enough time with vs. hospital midwife Z=5.82, p<0.001,cm>hm new mothers vs. health visitor n.s. (n=295) vs. family doctor Z=9.99, p<0.001, cm>fd hospital midwife: vs. health visitor Z=6.59, p<0.001, hv>hm vs. family doctor Z=4.64, p<0.001, hm>fd health visitor: vs. family doctor Z=11.6, p<0.001, hv>fd

note: in Tables 2 and 3 the following abbreviations apply: hv – hospital midwife; cm – community midwife; hv – health visitor; fd – family doctor

Table 2. Comparison of perceived behaviour of health professionals



play with breastfeeding mothers than with bottle-feeding mothers (p<0.001). No significant differences were reported in perceived attitudes towards breast or bottle-feeding moth-ers than other professional groups. Hospital and community midwives were seen as being more likely to expect mothers to breastfeed than were either health visitors or family doctors (p<0.001), with a weaker significance indicating that hospital midwives were seen as slightly more likely to expect this than were community midwives (p=0.001), and health visitors slightly more likely than family doctors (p=0.002).

Comparison of exclusive breastfeeders (n=125) and others (n=172) on the statementsThe ratings of the statements were compared between those exclusively breastfeeding and those offering some or all bottle feeds at one month postnatally (Table 4).

Women choosing to bottle feed were less likely than were exclusive breastfeeders, to agree that hospital midwives gave enough information antenatally about infant feeding (p<0.001). Women choosing to bottle feed were also less likely to think that hospital midwives spend enough time with new mothers (p=0.005). These women were less likely than those who were exclusively breastfeeding to see hospital midwives (p=0.002) and community midwives (p=0.004) as giving enough help to new mothers.

Women who were bottle-feeding were more likely to respond by agreeing with statements four and five, about the attitudes of hospital midwives, than were women who were exclusively breastfeeding (p<0.001). No differences were found in these statements for any of the other professionals. There were no differences between exclusive breastfeeders and others in terms of agreement that ‘This person expects mothers to breastfeed’. There was universal agreement that this statement was true for all the health professionals, though there was a perceived difference between the health professionals (Table 3).

DiscussionIn this paper, only responses to the first postnatal question-naire from the women of 23 years and over, and at one month postpartum, are considered (n=304). Seven women did not complete this section of the questionnaire and results are from the 297 responders.

The women responding to the questionnaire were all first-time mothers so possibly had limited prior experience of caring for a newborn infant.

Women in general were positive about the adequacy of information and help provided to them, and did not distin-guish between levels of information on infant feeding mat-ters provided by hospital and community midwives, or by hospital midwives and health visitors. However, community midwives were seen as being more supportive than health visitors. This could be because almost all women receive care from their community midwives in the antenatal period, and normally such care is not provided by health visitors for this population (SE, 2002). Feeding the infant is an aspect of motherhood in which new mothers need to feel confident in the level of care they are receiving, especially as they are devel-oping new skills and are likely to go home to an essentially

self-care environment within a very short time. The pressure on hospital midwives to give enough postnatal assistance to new mothers may reflect infrastructure issues with financial constraints influencing the number of midwives employed. The recent nationally highlighted shortage of midwives avail-able for employment (Ashcroft et al, 2003) is not, however, an issue in the geographical regions in this study.

The family doctor was seen by the women as being less supportive than were other health professionals with respect to infant feeding matters. This may reflect the fact that fam-ily doctors have little contact with pregnant women or new mothers in an advisory capacity, unless there is a health prob-lem, with substantially more health care being carried out by nursing and midwifery practitioners in community settings (McGuire et al, 2004).

It has been suggested that breastfeeding mothers require more contact with midwives than do bottle-feeding mothers (Cohen, 1994) but this may not be true in that, bottle-feed-ing is a skill which, like breastfeeding, needs to be learned and practised before a mother feels confident in its operation. A possible consequence of this approach by hospital midwives was identified by Daly et al (1998), who showed that 30% of bottle feeds made up by new mothers in an inner city population were incorrectly prepared, with 20% preparing milk of too high a concentration (Daly et al, 1998). Other studies have also demonstrated that bottle-fed infants are at risk from their mothers’ lack of understanding of preparation

statement health practitioners significant findings

this person spends community midwife: more time helping vs. hospital midwife Z=6.39, p<0.001, hm>cm mothers who are vs. health visitor n.s. breastfeeding than vs. family doctor n.s. those who are hospital midwife: bottle-feeding vs. health visitor Z=7.07, p<0.001, hm>hv (n=293) vs. family doctor Z=6.63, p<0.001, hm>fd health visitor: vs. family doctor n.s.

this person thinks community midwife: breastfeeding vs. hospital midwife Z=4.54, p<0.001, hm>cm mothers are more vs. health visitor n.s. important than vs. family doctor n.s. bottle-feeding hospital midwife: mothers (n=292) vs. health visitor Z=-5.23, p<0.001, hm>hv vs. family doctor Z=-3.98, p<0.001, hm>fd health visitor: vs. family doctor n.s.

this person expects community midwife: mothers to vs. hospital midwife Z=3.20, p=0.001, hm>cm breastfeed (n=293) vs. health visitor Z=3.16, p=0.002, cm>hv vs. family doctor Z=3.16, p=0.002, cm>hv hospital midwife: vs. health visitor Z=4.99, p<0.001, hm>hv vs. family doctor Z=6.89, p<0.001, hm>fd health visitor: vs. family doctor Z=3.00, p=0.003, hv>fd

Table 3. Comparison of perceived attitudes of health professionals

British Journal of Midwifery, deceMBer 2006, Vol 14, no 12 697


of artificial feeds (McJunkin et al, 1987; Harkin et al, 1999; Renfrew et al, 2003).

In this study mothers see hospital midwives as more likely than other health professionals to expect mothers to breast-feed, with community midwives second, health visitors third and family doctors fourth. This may lead to reluctance on the part of expectant or new mothers to discuss bottle-feeding with midwives, despite the fact that they are the people most available and knowledgeable to provide appropriate informa-tion and advice antenatally and in the early postnatal period.

Alternatively, hospital midwives may perceive bottle feed-ers as not requiring assistance with infant feeding, perhaps believing they could access it elsewhere, or considering that it is not a difficult skill to acquire. Women who were offer-ing some bottle feeds at one month postnatally were more likely than those exclusively breastfeeding to consider hospital midwives as having given less support both antenatally and

postnatally. Community midwives were also more likely to be seen by women giving bottle feeds as providing less help for new mothers. The Scottish Office policy review of maternity services (SO, 1993) led to earlier discharge following child-birth and since then there may not be enough opportunity for hospital midwives to spend time with women postna-tally. An increased workload for community midwives since implementation of the Framework for Maternity Services in Scotland (SE, 2002) may also mean that they have less time to spend with each mother at home. Community midwives may also choose to spend more time with breastfeeding moth-ers than with bottle-feeding mothers to meet the perceived demands of their local breastfeeding promotion strategies (NHS, 2001). Comparing the views of breast and bottle-feeding mothers, those giving bottle feeds were more likely to consider that hospital midwives give priority to those women who were exclusively breastfeeding. Bottle-feeding mothers were less likely to think they were receiving ‘enough’ informa-tion, time and help from midwives, compared with breast-feeding mothers. This indicates that they feel they needed more support than they were receiving. This finding should be taken in the local context of very low levels of exclusive breastfeeding beyond the first ten days (Information Services Division (ISD) Scotland, 2000) when contact with the mid-wife would characteristically cease.

While there is no doubt—in terms of health benefit—that

Women exclusively Women giving statistical breastfeeding some bottle feeds significance n=125 (mean) n=172 (mean) (Mann-Whitney test)

this person gives enough information about infant feeding to women before baby is born hospital midwife 3.43 2.94 p<0.001 community midwife 3.53 3.41 n.s. health visitor 3.32 3.15 n.s. family doctor 2.61 2.53 n.s.

this person gives enough help to new mothers with infant feeding hospital midwife 4.05 3.55 p=0.002 community midwife 4.21 3.87 p=0.004 health visitor 4.22 4.01 n.s. family doctor 2.73 2.63 n.s.

this person spends enough time with new mothers hospital midwife 3.71 3.35 p=0.005 community midwife 4.13 3.86 n.s. health visitor 4.24 3.99 n.s. family doctor 3.13 3.04 n.s.

this person spends more time helping mothers who are breastfeeding than those who are bottle-feeding hospital midwife 2.51 3.03 p<0.001 community midwife 2.28 2.31 n.s. health visitor 2.18 2.27 n.s. family doctor 2.18 2.27 n.s.

this person thinks breastfeeding mothers are more important than bottle-feeding mothers hospital midwife 2.17 2.75 p<0.001 community midwife 2.11 2.23 n.s. health visitor 2.06 2.15 n.s. family doctor 2.17 2.16 n.s.

Table 4. Comparison between breast and bottle-feeding mothers of the statement scores, for each professional group.


mothers see hospital midwives as more likely than other health professionals to expect mothers to breastfeed

‘’


breastfeeding is the ideal means of infant nutrition in all but exceptional circumstances, the provision of adequate support for women who bottle feed their babies is also important, whether this represents their original choice or whether this decision is made subsequently after a period of breastfeeding. Learning any feeding skill is crucial to effective infant nutri-tion, but particularly when the consequences of mistaken technique can be harmful (Renfrew et al, 2003). Inability to deal with bottle-feeding difficulties can result in traumatic interaction between mother and baby, with constant and inappropriate changing of feeds and the possibility of early introduction of solid foods. Bottle-feeding, and the associ-ated, perhaps consequent, early introduction of solids have been shown to contribute to illnesses in later childhood (Howie et al, 1990; Forsyth et al, 1993; Wilson et al, 1998). Since these studies did not include discussion relating to inappropriate preparation for and conduct of bottle-feeding it is possible that they have underestimated the influence of support and information about feeding on the welfare of bottle-fed babies.

These factors relating to the needs of bottle-feeding moth-ers are being recognized in the proposed Infant Feeding Strategy, currently under consultation (Anon, 2006), and it is hoped that this document will be utilized to full effect by health professionals.

LimitationsThere have been some factors of the study which limit its abil-ity to be generalized to the whole UK population.nThe overall recruitment rate to the study was low, though

in keeping with response rates to postal surveys in the literature. Ethics approval for the study did not allow reminder letters to be sent to women, so it was not pos-sible to enhance these numbers. The ethics committees had felt that since women had not been approached prior to sending of the first questionnaire, this questionnaire would be the test of whether they wished to be included in the study. Non-return therefore could indicate that they did not wish to be included, so reminder letters would have been inappropriate.

nYounger women were not included in these analyses, largely because there were few responses to the question-naires from this age group. It is likely that those who did respond had differing characteristics from those who did not respond and, as mentioned earlier, because there was a distinct bi-polar distribution of ages in both the popula-tion and in the sample, younger women may have differing characteristics from the older women.

nData for this study were gathered in 1998 and 1999. This may be considered to be rather dated, but there appears to have been very little published on support for bottle-feeding since that time. Given that most women do offer bottle feeds to their infants at some stage, this would seem a necessary topic to consider and research.

nIt is acknowledged that there is some bias in the three statements relating to attitudes but if this is taken in context, considering the relatively low level of exclusive breastfeeding in this population, the findings may still be representative of the whole.

ConclusionThis study has illustrated differences in mothers’ perceptions of antenatal information given, postnatal time spent with, and help given to new mothers by different health profession-als. The Baby-Friendly Hospital Initiative has been employed with enthusiasm for over a decade and midwives are now very skilled in helping mothers to breastfeed. However, hospital midwives were perceived by this sample of new mothers as giving less support overall than did other professionals, and were seen as more likely to favour breastfeeding women than those offering bottle feeds. Additionally, women who were giving bottle feeds were more likely than those exclu-sively breastfeeding at one month to feel this way. While this emphasis on breastfeeding may be in accordance with Baby-Friendly Hospital Initiative guidelines, this study questions the level of support for first-time mothers who offer bottle feeds to their infants.

There has been little published on how bottle-feed-ing mothers interact with health professionals. This study suggests that the relationship between new mothers and health professionals differs according to how they feed their infants. For a while anecdotal information has suggested this to be the case and it has been upheld by these findings. Although the study considered women of 23 years or over in an area which has a relatively low incidence of breastfeed-ing, the demographic characteristics of the sample compared with those of older first time mothers elsewhere in the UK render the findings of this study generalizable to the wider population. BJM

Ashcroft B, Elstein M, Boreham N, Holm S (2003) Prospective semi-structured observational study to identify risk attributable to staff deploy-ment, training, and updating opportunities for midwives. BMJ 327: 584–8Cairney P A, Alder E M (2001) A survey of information given by health professionals, about bottle-feeding, to first time mothers in a Scottish population. Health Bulletin 59: 97–101Cohen P (1994) Bottle battle heats up. Health Visitor 67(5): 153–4Daly A, MacDonald A, Booth I W (1998) Diet and disadvantage: obser-vations on infant feeding from an inner city. Journal of Human Nutrition and Dietetics 11: 381–9Forsyth J S, Ogston S A, Clark A, Florey C d, Howie P W (1993) Relation between early introduction of solid food to infants and their weight and illnesses during the first two years of life. BMJ 306: 1572–6Hamlyn B, Brooker S, Oleinikova K, Wands S (2002) Infant Feeding 2000. The Stationary Office, LondonHarkin K, Quinn C, Bradley F (1999) Storing methadone in babies’ bot-

British Journal of Midwifery, deceMBer 2006, Vol 14, no 12 699

Inability to deal with bottle-feeding difficulties can result in traumatic interaction between mother and baby, with constant and inappropriate changing of feeds and the possibility of early introduction of solid foods.

‘

’



Key Pointsn this article compares the views new mothers have of health

professionals’ attitudes and behaviours regarding infant feeding.

n Midwives were less likely than health visitors or family doctors to be seen by mothers as supportive, in terms of information, giving help or time spent with the mothers.

n Mothers felt that hospital midwives were more likely, than were other health professionals, to favour breastfeeding women over bottle-feeding women.

n Breastfeeding women were significantly more likely than bottle-feeding women to feel they received enough support for infant feeding from hospital midwives.

mula concentration in an outpatient population. Journal of Pediatrics 111: 848–50McLoone P (1995) Carstairs scores for Scottish postcode sectors from the 1991 census. Public Health Research Unit. University of Glasgow, GlasgowNHS (2001) Community Breastfeeding Policy. Tayside Primary Care NHS Trust, DundeeRenfrew, M, Ansell P, Macleod K L (2003). Formula feed preparation: helping reduce the risks; a systematic review. Arch Dis Child 88: 855–8SE (2006) Infant Feeding Strategy for Scotland - consultation document. Scottish Executive, EdinburghSE (2002) Implementing a framework for maternity services in Scotland. Scottish Executive Health Department, EdinburghShepherd C K, Power K G, Carter H (1998) Characteristics of responders and non-responders in an infant feeding study. Journal of Public Health Medicine 20: 257–80SO (1993) Provision of Maternity Services in Scotland. Scottish Office, EdinburghWhitehead E (2001) Teenage pregnancy: on the road to social death. International Journal of Nursing Studies 38: 437–46WHO (1981) Handbook of Resolutions and Decisions of the World Health Assembly and the Executive Board. In The Twenty-Seventh World Health Assembly (Conference), 1974. 11 World Health Organization, GenevaWHO/UNICEF (1981) International Code of Marketing of Breast-milk Substitutes. World Health Organisation, GenevaWHO/UNICEF (1989) Protecting, promoting and supporting breastfeed-ing: the special role of maternity services. WHO, GenevaWHO/UNICEF (1997) The International Code of Marketing of Breast-milk Substitutes: a common review and evaluation framework. World Health Organisation, GenevaWilson A C, Forsyth J S, Greene S A, Irvine L, Hau C, Howie P W (1998) Relation of infant diet to childhood health: the Dundee Infant Feeding Study. BMJ 316: 21–5

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tles puts young children at risk [letter]. BMJ 318: 329–30Howie P, Forsyth J, Ogston S, Clark A, Florey C d (1990) Protective effect of breastfeeding against infection. BMJ 300: 11–6ISD (2000) Scottish Health Statistics 2000. Chapter B: Childhood Information Services Division (NHS) Scotland. The Stationary Office (TSO), EdinburghLee E, Furedi F (2005) Mothers’ experience of, and attitudes to, using for-mula in the early months. School of Social Policy, Sociology and Social research (SSPSSR) University of Kent, CanterburyMcGuire M, Dagge-Bell F, Purton P, Thompson M (2004) Shaping maternity services in Scotland. Brit. J. Mid. 12: 674–8McJunkin J E, Bithoney W G, McCormick M C (1987) Errors in for-

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