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Who should deliver postnatal care in the UK?

September 3, 2014

 

The RCM has recently published a report with regards to women being discharged too early from hospital .  They quote a total of “40% of the women in the survey said they had been discharged too early”. To be honest I took heart, this meant that 60% felt they had gone home at the right time!   I agree we need to work on it but why highlight the lower number.

It also stated “two-thirds (65%) of midwives said the number of postnatal visits was determined by organisational pressures and not the women’s needs”. This was an interesting statistic and I believe reflects the way midwives are feeling about the changes in postnatal care, not necessarily a reflection of whether the changes are affecting outcomes for women and their babies. Other research would have to be done.

 

Nearly thirty years in the Midwifery business, both hospital and community based , I am old enough to remember when postnatal care included twice daily checks a day, morning and evening for the first three days. There were full physical checks of maternal and neonatal wellbeing and allowed access to women and their babies to give feeding support and lots of early parenting advice.

We then did daily checks up to the first ten days and then often kept women on until 28 days postnatal or up to six weeks if there were issues to support before transfer to the Health Visitor.

I also worked with midwives who remember a midwives role as supporting the family just after the birth, to the extent of making the family a meal and caring for other children. Men of course were not as available as they are now to support their partners in the first few days.

I think we have to acknowledge that in the world of the 21st century, how we deliver post natal care needs to change. There were 729,674 live births in England and Wales in 2012(ONS),

 

I believe we have similar health outcomes to other countries that do not have our level of postnatal input my midwives. In many countries women leave hospital to no ongoing support.  They access services if they need them.   The inevitable question rears its head. Why provide such an intensive service if you cannot prove its benefits?

Even in the Netherlands regarded as a best practice standard, a lot of the postnatal care was and is performed by Care assistants rather than expensive midwives. The Dutch Kraamzorg system  Giving birth in the Netherlands.  The focus of the midwife stops after the initial postpartum period.

 

So maybe it is time to really look at what women want in the postnatal period and who is best to provide that care.

 

Early discharge

It is my recent experience that these days many women want to go home quickly. This might be as a result of very busy postnatal wards, no sleep due to other crying babies or just wondering why they are there if they are not getting lots of support from staff.

In general medicine this early discharge is called “enhanced recovery”.  Hospitals are really not the place for well people. If all has gone well, women who delivered in birth centres are encouraged to go home a few hours after birth. There is no reason for them to stay in a hospital setting. We encourage them to go home.

There is a strong case however for women post caesarean section and difficult births to stay in, but only if they are going to receive one to one care in the postnatal period and provide rest and help with their baby cares etc.

I worked in the day when women after caesarean section would stay anything up to 5 or 6 days post-delivery.  But many women now are going home first day post CS out of choice, not because the hospital are making them go home. They get frustrated, waiting for the Paediatrician to come and do the initial baby check. But of course if they want to stay they should be encouraged to stay.  The hospital is not a prison.

Breastfeeding

It is clear that we should be supporting breastfeeding as the best way to start life for a baby. It is implicit in the role of a midwife to support breastfeeding. So yes there should be a lot of support by people to encourage that to take place as a general public health initiative.  The research suggests however that this is most successful when offered by peer group supporters. Peer supporters. Not all midwives will have had children, not all midwives will have breastfed.  Therefore it follows that those who have and have been successful at it might be the best people to provide support.

Signs of disease

It is also clear that parents need to be alert to signs of disease (NICE CG 37 2004) in themselves and their newborn babies so that they act promptly. They need to know what to do and where to go.  Other families across the globe where health services are well established seem to manage this without having frequent visits from an expensive midwife. There is probably some education and advice needed at the point of discharge but access to information is so available now that most parents can access advice quickly and promptly. The use of websites to provide this information needs to be explored as a resource for parents.

Yes there will always be the individual family who need more support and there is strong evidence that this is where we should be putting our energies, not into general post natal care for all, but individual PN plans agreed with the family.

Some parents may not want visiting at home. They see it as an intrusion having to wait in till the midwife has been.  Community midwifery can be fraught with frustrations and unexpected events so parents are often told the visits can be any time between 8 and 5pm. Can we really expect modern parents to wait in for us? Would this family best not be served by accessing postnatal support via a clinic with a timed appointment? 

This is the way a lot of postnatal care is being provided across the country. Yes it is very different from the old fashioned community midwife visiting programme but maybe it is better at meeting the modern family’s needs. Our population tend to be the age that access to the internet is part of everyday life. This needs to be exploited.

 

 Postnatal Mental Health

Psychological health in the postnatal period is indeed an issue.  Closing the Gap (DOH 2014) Section 16.  The number of women who are suffering depression and having difficulties coping in the postnatal period appears to be increasing.  But again this is about assessing the individual needs of the woman, not just implementing a general postnatal programme for all.  The mental health support networks however are poor, with many areas not having good postnatal psychiatric referral processes.  I believe this is an area where the General Practitioner can fill the current gap and support the woman and refer as required.  Yes of course extra midwifery visits at home may be required, but good mental health care is what is needed.

 

Perinatal mortality and morbidity statistics

What is clear is that our perinatal mortality statistics, even though low in comparison to developing countries,  are not improving despite having a very modern health service in the UK. There are critical issues with what happens around the time of birth and the standard of care that the women receives at this acute period in her pregnancy.  What happens at birth has been proven to have long term effects for the woman and her baby.  Surely this is the area of care that midwives should be concentrating on improving. This is why this area of care is prioritised by many Maternity Services across the country – this is cost effective use of the resources they have at the point where we need most improvement.

 

I believe after delivery a discussion should take place with the new mother and her partner. Their feelings with regards to postnatal care need to be talked through. Do they want visits at home or do they want appointments elsewhere? Offer them access to information by telephone? Can they be given advice as to where to go and what to do if there is a problem. I think the day has come when we may not need to do routine visits at home.

Some of you might be raising the child protection or domestic violence flag at this point. Of course seeing the family in their home environment can help you discover families in need. But antenataly you do have many months to get to know this family if continuity of carer is supported. The old routine 36wk home visit to discuss labour is a point of care that I personally believe is now sadly lacking, as many midwives do bookings and most of their antenatal care in clinics. My personal opinion is that at the very least the booking visit and the 36wk appointment should be done in the home.

If community midwives were doing less postnatal visiting maybe this would be possible.

 

In many places the postnatal visits now follow a very minimal pattern.

  • Community midwife visits day after discharge from hospital to make sure all OK since home.
  • Day 3 visit for babies born by CS or difficult delivery to weight the baby. This is to highlight babies who are not establishing feeding.
  • Day 5 to administer the Neonatal screening and most babies are weighed.
  • Day 10. Discharged to health visitor baby weighed.

In many areas the day 3 and day 5 visits are done by Midwifery Support Workers rather than midwives as the focus is on the baby care rather than the mother. In some areas the access to accurate weighing scales is still an issue, limiting what can be done by each practitioner.

This is not to say the midwife might not visit more often, but it will be to meet the needs of the individual not visiting just because the programme says they should. Midwives have to prioritise care to women at most need and utilise other support workers either employed care assistants or peer breastfeeding supporters,

 

Whether reduced postnatal midwifery visiting is having an effect on outcomes can be measured by the maternal and neonatal readmission rates and the reasons for re-admission. If this increases as midwifery postnatal visits reduce, then there may be a case for increasing support in the community again. I am not currently aware that as programmes have changed over the last ten years, that there has been a dramatic rise in re-admissions. 

Often women return for a real need such as secondary postpartum haemorrhage or wound infections.  These may happen anyway whatever the midwifery postnatal visiting programme. the woman just needs to know how to access help if she has symptoms.

Babies are readmitted and the reason is often associated with poor feeding. This is monitored by many hospitals. Again my opinion is that the support of breastfeeding is best done by a peer support person who can offer the best experiential advice and support.

 

Lastly with reference to the wider world,  where issues of basic cleanliness and hygiene due to lack of disposable sanitary protection leading to mothers deaths The Indian sanitary pad revolutionary , brings it all into focus for me.

We have to use midwifery expertise when it can be most influential.  I believe a lot of postnatal issues that used to be dealt with by midwives could be provided by other services, personnel and that society in general has to take some of the burden. This opinion will not go down well with midwives who have specialised in the postnatal area of care.

It is well documented that we do not have enough midwives to provide one to one care in labour in many units across the UK. Surely at the present time this is where we should focus our energies. What we do then has been shown to have an effect on the mother and the baby for life.

 

 

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One Response to “Who should deliver postnatal care in the UK?”

  1. cathy ashwin Says:

    Hi Helen,

    A very interesting article P/N care is a very neglected area. I would like to invite you to write a paper for MIDIRS Digest on this topic. If this is something you would be interested in, please get in touch:
    c.ashwin@midirs.org
    Thanks
    Cathy Ashwin. Principal Editor.


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