Study design and participants

This qualitative study was part of the Postnatal Care Project that aimed to explore mothers, and their partners’ overall experiences of a Swedish home-based postnatal care model^9,10. Inclusion criteria were: be a Swedish-speaking mother that had participated in the new home-based postnatal care model, had completed a web-based survey about her postnatal experience, and had agreed to participate in an in-depth interview study.

Study setting

The home-based postnatal midwifery care model was implemented in September 2015 at a hospital in Stockholm, Sweden. A care model was offered to those families meeting the criteria for early discharge (6–24 hours after birth). The home-based postnatal care included daily telephone contact, home visits, and hospital visits, as preferred and needed during the first week after the baby’s birth. The structured follow-up included daily telephone contact by a midwife in the project and an opportunity to call a hospital midwife around the clock if additional support was needed. During the telephone calls, the mothers could book home visits by a midwife as preferred. Previous reports for the project that involved 180 mothers described that they were most likely to have been discharged between 6 and 12 h after childbirth (56%). Most mothers had a positive postnatal care experience from the postnatal model of midwifery care (mean VAS score=8.74, SD=1.438)⁶.

Data collection

An evaluation of the Postnatal Care Project was initiated 18 months after implementation. In total, 180 mothers completed a questionnaire, and of these, 69 mothers indicated that they could be contacted for a follow-up interview. A total of 35 mothers were contacted via email/short text messages to confirm interest in participation, and 24 mothers accepted to participate in a telephone interview. The qualitative semi-structured audio-recorded telephone interviews were conducted between April 2017 and September 2017 by the first author at a time and day preferred by the participants. The interviews followed an interview guide (Table 1). The participants were encouraged to be themselves and be in a friendly atmosphere. All participants talked freely, and no one withdrew their participation. During the last interviews, the data started to repeat itself, which was understood as a sign of saturation, and the decision was made to terminate the data collection. The length of the interviews varied between 27 and 114 minutes (mean: 58 min). Data collection was carried out between 5 and 18 weeks postpartum (mean: 11 weeks).

Both authors have extensive experience in qualitative methods. The study participants had not met or been cared for by the authors during their postnatal care period. The first author was the project leader who implemented home-based midwifery care.

Background variables were age, civil status, education level, parity, time of hospital discharge after birth (6–12; >12–24; >24 hours) if the discharge was regarded at the right time (Yes; No, I had been able to go home earlier; No, I needed a longer stay), overall experiences of birth and postnatal care satisfaction (measured on a Visual Analogue Scale (VAS), from 0=very negative to 10=very positive), and preferred model of postnatal care for next child (home-based, hotel-based, traditional hospital-based, do not know).

Data analysis

The data were analyzed using thematic analysis, according to Braun and Clarke^11,12. The first author familiarized herself with the data, which included transcribing data verbatim, reading and re-reading the data, and noting initial ideas. From the second phase, together with the other author, included generating initial codes with relevant features according to the aim and collating data relevant to each code. Codes were sorted into the nine potential themes:

The potential themes were reviewed and collapsed into three new preliminary themes:

The ongoing analysis explored three new themes that were explained by the main theme: ‘The home-based postnatal care model facilitated a smooth succession into motherhood’. The last phase of the data analysis was to include a selection of vivid, compelling quotes in the study’s findings¹¹ (Table 2).

Ethical considerations

Participation in the study was voluntary, and informed consent was collected from all participating mothers before the interviews started. All participants were informed about confidentiality and that they could withdraw their participation anytime. The study received ethical approval from the ethics committee in Stockholm.

Description of the study participants

The mean age of the 24 participants was 34 years. One woman was a first-time mother, and the other mothers had 1–4 children. All mothers lived with their partners and were more likely to have a Swedish origin and higher education. The mothers were discharged between 6 and 24 hours after the birth of their baby, and most of them (91.7%) believed that they had been discharged at an appropriate time. Of the women, 33.3% rated their overall postnatal satisfaction as very positive (VAS score=10). Twenty (83.3%) of the 24 mothers stated that they preferred home-based postnatal care for the next child (Table 1).

Mothers felt ‘not left adrift’ when cared for by home-based postnatal midwives

A structured follow-up involved a smooth succession into motherhood and included frequent contact with professionals during the first week after the baby’s birth. The follow-up included assessments of the baby’s and the mother’s well-being. The mothers felt taken care of and not ‘left out’. A sense of security was experienced, and they were not ‘left to their own devices’. The mothers described that the home-based postnatal care concept contributed to a good start in motherhood.

To call a midwife directly without going through a switchboard if they had questions was appreciated by the mothers. It was perceived as easy, positive, as extra security, and nice that a midwife was available for them. The mothers missed that the midwives in the project could not take the calls even at night, when instead, an ‘unknown’ midwife at one of the postnatal wards answered who was not fully familiar with the families’ needs and not always documented the telephone call. When the project midwife called the mothers daily during the first week after the baby’s birth to ask for the family’s wellbeing, they experienced the contact as adequate, good, safe, and nice. It was appreciated not to have the responsibility to make the contact themselves. A mother with previous children explained:

The mothers thought it was easy to ask questions via phone calls. When the midwife made the call, they felt that they did not disturb the midwives as when they had made the contact themselves. One mother was not satisfied with the telephone contact as it was experienced as short and impersonal.

A home visit gave the mothers additional support, a midwifery assessment of the baby’s well-being, and getting help with breastfeeding issues. It was an occasion when the family easily could ask their questions and get help based on their home conditions. The home visits were experienced as nice, natural, pleasant, good, and luxurious, a major bonus that gave them security. Receiving home visits was also appreciated because they did not have to worry about transportation to the hospital for return visits. One mother of three children expressed:

The mothers appreciated being offered a check-up without having to pre-book an appointment. An assessment that gave the confidence to check if everything was normal. A mother of four children said:

The mothers thought that the midwives in the project had an adequate focus on breastfeeding, which was necessary as breastfeeding was described as demanding and fills the hours around the clock, especially during the first week after the baby’s birth. The mothers were usually satisfied with breastfeeding support, which was perceived as valuable. A mother of two children said:

One first-time mother wanted to receive practical breastfeeding support, but it was not easy to coordinate this during the home visit (Participant 7). Another mother of two children described that the staff during the hospital check-up did not have the time needed for breastfeeding support and that they gave inconsistent advice (Participant 10).

The structured follow-up included a pediatric examination and a hearing screening at the hospital for the baby when needed. The project midwives arranged for the follow-up at the hospital and met the family upon arrival. The return visit to the hospital was perceived by most mothers as good, smooth, flexible, fast, and efficient. The mothers thought this was good and positive; they were satisfied and experienced safety. Not all mothers received information about what the pediatrician assessed. One woman with two children described what information would have meant to her:

Professional midwives with authority guided the way into motherhood

Mothers experienced the midwives as being well-read, having a clear plan of action, experienced, skilled, and professional, which were considered positive, good, and safe. Midwives’ health checks and adequate information created safety. The mothers thought of it as good, positive, nice, and safe that the midwife, at an early stage, checked and attended to something that was not right with the baby, the mother, or the breastfeeding. The mothers appreciated that the babies’ weight was examined, that the general condition was assessed, and that newborn jaundice was checked, as well as receiving information about how to nurse the baby. It was important for the mothers to get information about the baby’s health, which led to them being calm if everything was fine.

When the mothers felt listened to, received good, clear, well-adapted information, and received correct and nice treatment, they experienced participation in postnatal care. This approach led to the midwife and the mother meeting on equal terms in the conversations and that the mothers did not feel overlooked or that anyone ‘spoke above their heads’. A second-time mother explained:

Receiving information about the psychological aspects of childbirth was considered important. It was described how some midwives mostly focused on the baby, which was perceived as good, but also that midwives could lack a deeper focus on the mother’s well-being. One mother of four children described the difficulties of explaining oneself as a mother:

The mothers thought it was important, friendly, and safe that the midwife answered their questions. Furthermore, it was appreciated when the midwife asked questions about breastfeeding, how everyone in the family was feeling, and their family’s life situation, to discover if additional support was needed. The mothers appreciated when the midwife offered conversations about their birth experience, listened to the mothers and took them seriously, and when their partner became involved in the conversation.

The midwives asked questions about what the mothers knew, and with this approach, the mothers perceived themselves as participatory, competent, and safe, and became involved in influencing their postnatal care. A mother of three children said:

The midwives were generally described as not giving their own opinions. But, it was described by one mother of three children how a midwife had expressed her personal opinion about how pacifiers are not needed for a breastfed baby. This was perceived as an unprofessional statement:

Kind and responsive midwives were appreciated, and mothers experienced getting a friendly, pleasant, and nice response from the midwife. The mothers felt that the midwife listened to them and that they cared about the families and wanted the best for them, which created a sense of security in the mothers. Two mothers with previous children described:

The midwives were perceived as relaxed and calm, and they worked without stress even though the mothers may have experienced the situation as stressful. The mothers felt that there was enough time for them, even though the midwives most likely very busy. This approach was perceived positively and created a sense of security and a feeling of being strengthened in one’s parental role. A second-time mother described this as:

Individual care and support by the same midwife were preferred. The mothers described that they were not checked according to a specific template and were not questioned. They were usually given coherent individualized care and an opportunity to influence their postnatal care. The midwives were described as up-to-date on each family’s situation and needs, which made the mothers feel that they were professional and trusted the mothers’ stories and experiences. The mothers appreciated meeting the same midwife at their contacts with the home-based postnatal care during the first week, which was perceived as very nice and personal. A woman of three children described this as:

Sometimes the mothers met different midwives and could experience it as dreary and impersonal. A mother of three children explained:

The home is a safe and secure space for new mothers

The mothers experienced feelings such as practical, nice, cozy, fun, and comfortable, the best thing that could happen when receiving postnatal care in their home because they got peace and quiet. They could more easily get into family life, involve any siblings with the newborn baby, and get started with breastfeeding. The home-based postnatal care concept was perceived as practical and flexible for the whole family. One mother with two children said:

Receiving care at home instead of in the hospital was perceived as safe and secure as they could avoid infections such as respiratory syncytial virus both for the newborn baby and for any siblings. Being cared for in a hospital they believed could make them feel sick even though they were healthy.

Being in their home could be perceived by some as not getting adequate rest when they immediately entered their everyday lives. One second-time mother said:

Strengths and limitations

This study provided in-depth and detailed information²³ about mothers’ experience of receiving home-based postnatal midwifery care. A strength of this study was the lengthy interviews rich in content. Data were collected by telephone interviews, a method considered convenient as informants could decide for themselves the time of the interview and attend the interview without having to travel²⁴. Nevertheless, negative consequences of telephone interviews may be that participants being interviewed through the telephone might be less cooperative than during a face-to-face interview and that body language is missed out²⁵. Furthermore, all responders but one had previous experiences with hospital-based postnatal care and were asked to elaborate on the pros and cons of different care models. However, an RCT is preferable when aiming to compare and evaluate different models of postnatal care. Further limitations were that the participants were mainly multiparas, mothers who lived with a partner, had an uncomplicated pregnancy and a vaginal birth and a healthy baby, which should lead to caution of transferring the findings to other groups of new mothers. Beneficial was that most of the mothers had been allowed to choose between either home- or hospital-based postnatal care⁶. Both authors have extensive experience in qualitative methods. The study participants had not met or been cared for by the authors during their postnatal care period. The first author was the project leader who implemented home-based midwifery care. The Standards for Reporting Qualitative Research were used to ensure the transparency of our study²⁶.