Context of the postnatal care in the present study

The hospital under study offers a traditional postnatal ward, mainly for women with complicated pregnancies or births. Women in need of breastfeeding support usually stay at the postnatal ward. Healthy mothers and babies can go home directly from the labour ward after six hours and the first paediatric examination. A hotel ward closely situated to the postnatal ward is often used as an in-between place to stay after discharge. The hotel ward is not staffed with midwives, but if the women need support they are instructed to call to the outpatient clinic or the postnatal ward. If the baby is admitted to the neonatal ward, parents have co-care at the neonatal ward. Partners are usually able to stay overnight in the labour ward before going home, in the hotel ward, or, in most cases, in the postnatal ward.

There is also a postnatal outpatient clinic connected to the postnatal ward, where discharged women are followed up after birth. The midwives who work in the postnatal outpatient clinic make daily phone calls to all discharged women, who thereafter come back to the postnatal outpatient clinic with their babies around 48 hours after birth, to give a blood sample for the detection of multiple metabolic disorders (PKU-test). Five to seven days after birth there is a second paediatric examination performed at the clinic.

Problem area

Previous studies identified several aspects associated with satisfaction with postnatal care. While some aspects seem to become more positive over the years, there is still a need to further investigate factors, whether or not they have improved. The aim of this study was to describe women’s assessment of postnatal care in 2017 in a Swedish hospital, and to compare this with women who gave birth in 2006.

Design

A comparative study was conducted of two cohorts of women who gave birth in a hospital in the middle north part of Sweden. The hospital has an annual birth rate of around 1700.

Sample

Women who gave birth during a 6-month period in 2006 and in 2017 were identified from the electronic database at the hospital and were sent a questionnaire that included a letter with information about the study and a pre-paid envelope. In 2006, the questionnaires were only sent to Swedish-speaking women, but were translated into the five most common languages in the area in 2017 (English, Dari, Arabic, Somali, and Tigrinya). A returned questionnaire was considered consent. Four to six weeks after the questionnaire was sent out, a reminding letter with a new questionnaire was sent to non-respondents. Concurrent with the introduction of the postnatal outpatient clinic, efforts were made to improve postnatal care and create a better work environment, based on the results from the 2006 survey¹⁹. This was done by arranging workshops focusing on establishing a joint vision and value-based care. All members of the staff were involved in the workshops and negotiated that respectful, individualized care should be at focus. Changes in staff’s attitudes were the most important improvement, but some practical changes also occurred. One example was that the outpatient clinic introduced a follow-up program consisting of daily telephone calls to families who either went home after six hours or stayed at the hotel ward. Return visits were organised, prior to discharge, with a specific time twice a day, for consultation with the paediatrician and a midwife. Earlier, the families had to sit in the waiting area for up to two hours, until the paediatrician showed up. During the scheduled time for the re-visit, the families also met with the midwife in charge of the outpatient clinic, and had the opportunity to receive health check-ups and breastfeeding information if needed. For women who needed to stay on the postnatal ward, efforts were made to secure that the partner could stay overnight. Another improvement was the introduction of a structured breastfeeding observation for all women and babies.

Questionnaire

The questionnaire was previously used in studies performed in 2004 and 2006 at the same hospital^13,14,19 and the same questionnaire was also used in 2017. Sociodemographic characteristics (age, marital status, country of birth, education level and parity) as well as pregnancy and birth related questions (length of pregnancy, onset of labour, mode of birth, self-reported complications and women’s birth experience) were collected. Questions about the time of discharge from the postnatal ward, experience of length of hospital stay and model of postnatal care were also included in the questionnaire. Moreover, detailed questions about the content of postnatal care (information, practical issues, organizational issues, and women’s experiences of treatment by the staff) and some overall questions about satisfaction with the medical and emotional aspects of care, as well as an overall assessment with postnatal care were collected. Satisfaction with the detailed questions and the overall aspects were assessed on a 5-point Likert scale, with 1 being ‘Very Satisfied’ and 5 ‘Very dissatisfied’. For some of the detailed questions there was also an option to tick the alternative: ‘Did not receive information/practical help’.

In the analysis, the scales were dichotomized into: 1=Very satisfied, and 0=Not very satisfied. The choice of using ‘Very satisfied’ was based on an assumption that it was important to get an evident picture of what really works in order to improve the care^19-22. A reliability test yielded a Cronbach alpha value of 0.84 for the 2006 sample and 0.86 for the 2017 sample.

Analysis

The 2017 sample was compared with data from the 2006 survey, using the same questionnaire. Descriptive statistics and chi-squared tests were used to present the participants. Crude and adjusted odds ratios with a 95% confidence interval were calculated for the explanatory variables. The study was approved by the Regional Ethics committee at Umeå University Dnr 2004-134 and 2017-442-31.

Women not receiving information/practical help

Some women (7–30%) reported they did not receive information about some aspects of postnatal care. In order to identify if there were particular women who reported that they did not receive information or help, we analysed their background characteristics. Multiparous women were more likely to report not receiving information about bodily changes (p=0.026). Multiparous women (p=0.016) and those delivered by a caesarean section (p=0.036) were more likely to report not receiving information about emotional changes (p=0.003). Lack of breastfeeding information was reported by multiparous women (p=0.000) and those who had a caesarean section (p=0.041); these groups of women also reported a lack of information about the baby’s needs (p=0.016 and p=0.010). Women aged 35 years or more, as well as multiparous women, were less likely to receive practical information about how to take care of the baby (p=0.030 vs p=0.000) or hands-on breastfeeding instruction (p=0.003 vs p=0.000), compared to their counterparts (younger women and primiparous women).

Table 4 shows women’s overall assessment of postnatal care. There was an increase in satisfaction from 2006 and 2017 for the medical and emotional aspects, as well as the overall assessment of postnatal care. Primiparous women were more likely to be satisfied with the medical (OR=1.8; 95% CI: 1.25–2.65) and emotional (OR=1.5; 95% CI: 1.01–2.28) aspects of postnatal care, compared to multiparous women. Women delivered by caesarean section were less likely to be satisfied with the emotional aspects of postnatal care (OR=0.3; 95% CI: 0.21–0.56). There were no other differences in background data and satisfaction.

Length of stay

Almost 64% in the present study went home within 48 hours, regardless of mode of birth. This is slightly more compared with data from a Danish population-based study reporting that 59% went home within 50 hours after birth²³. We do not have the exact time of discharge, but it is unlikely that it deviates from the national statistics⁵. It is, however, important to notice that women who spent their postnatal stay in the hotel ward were discharged from the hospital (administratively), although the hotel ward is situated next to the postnatal ward. The hospital statistics could therefore be misleading; probably more women who lived at a long distance from the hospital used the hotel option and stayed until the blood sample for the metabolic test was taken and then answered the time they left the hospital and not the time of discharge.

We also found that the majority of women assessed the length of stay sufficient, which indicates that the concept of early discharge is the norm and is well established in Sweden. From a clinical perspective, concerns have been raised about declining breastfeeding rates because of early discharge, but research findings have not yet been able to demonstrate any association between early discharge and breastfeeding rates^2,24,25. Freedom to decide when to go home, however, has been reported as important for postnatal women¹⁷.

Model of postnatal care

The results showed a decline in the use of the hotel ward. When the hotel ward was introduced it became popular, being an in-between option for parents to feel secure and to rest together after the birth^14,19. One explanation for the increase in parents going home directly from the labour ward (usually around six hours after birth) could be the structured hospital’s follow-up program of daily telephone calls and scheduled return visits that was introduced after the workshops.

Content of care

For most of the variables studied there was an improvement over time. This might be due to the extensive work being done in the clinic between the two periods, in terms of quality improvement, with workshops organised to strengthen the vision and the values of the clinic. The structured way of follow-up after discharge with daily telephone calls and a structured re-visit might also have helped.

Women who might need more care

Despite the positive development in most of the areas studied, we identified women that might need more attention and information. It seemed important for multiparous women to access information to the same degree as first-time mothers. One explanation could be that staff may assume the experienced mothers have all the information and skills they need. This is not always the case, as shown in a Canadian study of 6421 women. The researchers reported that primiparous and multiparous women perceived inadequate information on the same topics and to the same extent²⁶.

Women in the 2017 sample were most satisfied with the partner’s opportunity to stay overnight, medical checkups for the baby, and treatment from staff, with 57–60% reporting as ‘Very satisfied’. The aspect with the lowest ratings were information about pelvic exercises, information about emotional changes following birth, and practical information about how to take care of the baby (14–17% reporting ‘Very satisfied’). Still, it is important to notice the proportions of women reporting that they did not receive information/practical help. Barimani and Vikström¹⁷ reported, from a focus group study, that parents emphasized the value of consistent advice about breastfeeding, sufficient check-ups, practical help and information about infant care, and reassurance from the staff.

Overall assessment

Although there was an increase in the proportion of women who reported being ‘Very satisfied’ with their postnatal care from 2006 to 2017, it is important to notice that the proportion of satisfied women was quite similar to that reported in a 2008 regional study that included the same hospital, as well as two smaller hospitals⁷. The smaller hospitals generated higher proportions of satisfaction. The trend of higher satisfaction in this specific hospital under study probably mirrors the attempts to improve the quality of care after the survey in 2006⁷.

In a regional study covering three hospitals⁷, the overall questions of satisfaction were similarly worded as in the present study. Looking only to figures from the same hospital as in the present study, 39% were very satisfied with the medical aspects of postnatal care in 2008, which in the present study (2017 sample) was around 31%. Quite similar proportions assessed the emotional aspects (24%) and the overall assessment (34%) from 2008 to 2017. In the national survey quite similar proportions were also reported; with 26–35% being ‘Very satisfied’⁶. The question remains: is it possible to increase satisfaction with postnatal care or should hospital managers and women be content with this level of satisfaction? We argue that we still have the challenge to continue developing postnatal care – ‘what is, could still be better’⁷.

Several studies have focused on improvement of postnatal care and increased maternal satisfaction, such as midwifery continuity models of care²⁷, interventions to support effective communication^17,26,28, home visits^29-31, involvement in decisions about leaving the hospital²³, and, most importantly, a health system that places the woman at the centre of care⁹. Early postnatal care in hospital provides the opportunity to form the foundation for secure parenthood, and attempts to guarantee a safety net should therefore be promoted. However, staff in postnatal wards need to have the time and resources to develop such care.

Limitations

This study has certain limitations. The observational design makes it impossible to draw any finite conclusions. The fairly low response rate in the 2017 sample is another problem, regardless of the reminding procedure, which might have introduced selection bias. One strength, though, is the translation of the questionnaire for the 2017 sample, allowing non-Swedish speaking women to be included in the study. Another issue is the dichotomization of variables, such as comparing being ‘Very satisfied’ with ‘Less than very satisfied’. However, Carr-Hill²¹, and Brown and Lumley²⁰ , suggested that all levels other than being ‘Very satisfied’ should be considered as suboptimal care, and being less than ‘Very satisfied’ indicates areas that could be improved.