Worldwide, the postnatal period is increasingly referred to as the fourth trimester of pregnancy (Karp, 2002; Mehta and Srinivas, 2021). However, postnatal care remains limited compared to antenatal and intrapartum care (Bhavnani and Newburn, 2010; Verbiest et al, 2018). The last decade has been associated with rapid changes in maternity services. Internationally, the length of hospital stays during the postnatal period has decreased (Barimani and Vikström, 2018; Goodwin et al, 2018), in line with increasing caesarean section rates, where women require more extensive/intensive care (Royal College of Midwives, 2014). At the National Maternity Hospital (2019), an urban maternity hospital in Ireland, the birth rate has fallen by 20% in the past decade (birth rate of between 8000-10 000 per annum). However, there has been a significant increase in caesarean sections from 19.9% in 2009 to 30.3% in 2019 (National Maternity Hospital, 2019). The same trends are identified throughout Ireland, where approximately 15% of women have operative vaginal births and 34% of women are delivered by caesarean section (Health Services Executive, 2019). Reasons for this have been identified, including that the number of women accessing private obstetric-led care in Ireland has increased; women who attend private obstetric-led care are more likely to birth by caesarean section or operative birth (Lutomski et al, 2014) and women who seek private obstetric care are more likely to have infertility issues, multiple pregnancies, a history of miscarriage, and be over the age of 35 years (Turner et al, 2020). Also, Irish women have their first baby later in life (Central Statistics Office, 2020) and age is a significant risk factor for birthing by caesarean section (Brick et al, 2020; Turner et al, 2020). The impact of the increased caesarean section rate will be most significant in the postnatal setting, where increased operative rates of birth are associated with more postoperative care (Brosnan et al, 2021). As postnatal service requirements increase, maternity care options remain inconsistent throughout the country.
In Ireland, after discharge from a maternity unit or community midwifery services, which generally occurs between 2–5 days postnatally, women receive a visit by a public health nurse (who does not require midwifery training) within a day or two of discharge from the hospital. They then receive a 2-week check-up by their GP for their baby and a 6-week check-up for themselves and their baby. This postnatal check is often a quick courtesy visit. The National Maternity Strategy for Ireland 2016–2026 recommends reviewing women between 3 and 4 months following birth (Department of Health (DoH), 2016). This service is not currently in place in Ireland, and while recommended, there are no current plans to introduce this quality improvement initiative in the near future (Cullen, 2019). In fact, 5 years since it was introduced, many of the key objectives set out in the strategy have yet to be actioned, and the DoH subsequently cut allocated funding substantially for the implementation of the Strategy, with reports that only 11% of the initial €8 million budget was made available (Cullen, 2019; Molloy, 2020).
Ireland's DoH (2016) has stated that ‘the population and their needs play an integral role in shaping the delivery of maternity care services to women and their families’. As such, it is vital to assess these ever-changing needs in order to determine how they impact care delivery requirements and how care can ultimately be improved (Schmied and Bick, 2014; DoH, 2016). With the consistent reduction in the birth rate, one would assume that more time would be available for supportive, women-centred care. In-depth research into the reasons for ongoing reports of inadequate postnatal care is warranted.
As part of a broader multi-methods study to ascertain current workload requirements for postnatal hospital care and to make recommendations on how these may best be met, this paper presents midwives' and healthcare assistants' experiences of the changes in postnatal care over the past decade and challenges to providing care in the current context.
Methods
As a result of its appropriateness in researching experiences through time (Bleakley, 2005), a narrative approach to the inquiry process was used, which is a qualitative research methodology (Chase, 2005; Riessman, 2008). This was chosen to better understand the participants' experiences through stories and information sharing and exploring their cultural, physical and social environment that impacts their individual experiences (Haydon et al, 2018).
Setting and sampling
The study took place in an Irish urban maternity hospital. Women can choose private or semi-private obstetric-led care or private community midwifery care in Ireland. Alternatively, women can choose the standard public option. In some geographical areas, women can access a public community midwifery service affiliated with specific maternity units, such as at the research site for the present study. Private care includes continuity of care with an obstetric consultant, birth facilitated by the consultant and a private postnatal room. Midwives provide labour and postnatal care with overview from the consultant. Semi-private care includes consultant-led antenatal care and a semi-private (4-bed) postnatal room. Labour and postnatal care are provided by midwives with an overview by the consultant. Midwife-led care involves continuity of care by a team of midwives. Care during labour and birth is provided by midwives, unless deviations from the norm are identified. A small percentage of women choose to have a home birth facilitated by hospital community midwives. Postnatal care is provided by midwives. There is no charge for women who choose public or midwife-led care.
Convenience sampling was used to recruit participants. All midwives, midwife managers and healthcare assistants who work in the three postnatal wards (private, semi-private and public) were invited by a gatekeeper (a postnatal ward midwifery manager) to participate in a focus group. Relevant information about the study was provided in a participant information leaflet. The focus groups were facilitated by a female research assistant with several years' experience in qualitative and action research, who works at the research site as a staff midwife and in a research capacity and was known by some of the study participants. The co-facilitator was the research lead who took notes on non-verbal communication and asked for elaboration where necessary. A total of 15 participants were recruited for the study: 13 midwives and two healthcare assistants. These participants were broken into separate focus groups: those with over 10 years' experience and those with less than 10 years' experience.
Data collection
Focus group discussions were seen as the most appropriate social medium for the active construction of the knowledge to be gained in this inquiry. The midwives and healthcare assistants told stories and shared their experiences. Both focus groups had the same discussion guide, with different midwives and assistants in similar career stages. This was carefully considered and was decided to be appropriate to identify themes that emerged from each of the separate groups, which added strength to the data analysis process. The participants with more than 10 years' experience would likely have different stories to tell when discussing how care has changed in the past decade. Although the focus groups were semi-structured, with certain questions being asked in both focus groups, the participants were encouraged and given the freedom and flexibility to tell their stories of their experiences of working in the postnatal ward and the changes they have witnessed and experienced over the past decade. Focus groups were audio-recorded, with consent, and transcribed verbatim by the research assistant within 5 days of each focus group. When transcribing, each participant was given a pseudonym to maintain confidentiality, only known to the research assistant and lead researcher. Each focus group lasted approximately 1 hour. Data saturation was achieved after the two focus groups.
Data analysis
Transcripts from the focus group interviews were analysed thematically (Attride-Stirling, 2001). Multiple readings of the transcripts were followed by a second stage of considering the dataset as a whole and identifying connecting themes. The basic themes were created when recurring words, phrases or metaphors were used. As a new theme was identified, it was coded. All codes were then reviewed by three members of the research team and presented as basic (sub) themes. The relationships between themes were examined and sorted into organising themes (categories). Validation of the themes was achieved through discussion with the entire research team to confirm findings. NVIVO 12 was used to organise research data to make retrieval of the data quicker and more efficient. Analysing multiple codes allowed the researchers to identify themes across the datasets.
Ethical considerations
Ethical approval was granted in November 2019 by the hospital's research ethics committee. Written permission was obtained from each participant to allow the conversation to be audio recorded and for the research team to use and analyse the pseudonymised data. All participants signed non-disclosure agreements.
Results
Focus group 1 comprised midwives and healthcare assistants who had been qualified for less than 10 years (n=8) and focus group 2 comprised midwives and healthcare assistants who had been qualified for 10 or more years (n=7) and included midwifery managers (Table 1). The two focus groups were held in February 2020.
Table 1. Demographic characteristics of focus group participants
| Characteristic | Frequency, n=15 | ||
|---|---|---|---|
| Focus group 1 | Focus group 2 | Total | |
| Job title | |||
| Healthcare assistant | 1 | 1 | 2 |
| Staff midwife | 7 | 3 | 10 |
| Clinical midwife manager 1 | 0 | 2 | 2 |
| Clinical midwife manager 2 | 0 | 1 | 1 |
| Experience (years) | |||
| Mean | 4.125 | 15.785 | 9.567 |
| Minimum | 0.75 | 10 | 0.75 |
| Maximum | 9 | 25 | 25 |
| Age (years) | |||
| ≤25 | 0 | 0 | 0 |
| 26–35 | 5 | 0 | 5 |
| 36–45 | 3 | 4 | 7 |
| 46–55 | 0 | 3 | 3 |
As part of the broader study exploring the current requirements for postnatal care, rich data were gathered from the midwives and healthcare assistants as they discussed and shared how their roles and responsibilities have changed over the past decade and the challenges faced in the current context of postnatal maternity services. The midwives and healthcare assistants shared the same views, regardless of experience or profession. A total of 17 basic themes were extracted from the transcribed text. These were then grouped into three organising themes, namely ‘woman-centred care’, ‘historical issues revisited’ and ‘evolving roles’, under an overarching global theme entitled ‘postnatal care in the current context’. Four basic themes, relevant to the aims of this paper, will be discussed here. These are ‘clinical characteristics and morbidities’ (evolving roles theme), ‘protocols and procedures’ (evolving roles theme), ‘the two-tiered system’ (historical issues revisited theme) and ‘women need more time’ (woman-centred care theme).
Evolving roles: clinical characteristics and morbidities
When exploring how their roles have evolved, the participants discussed the increased complexity of the women in their care. ‘A lot of high-risk cases are coming’, according to Prisha from focus group 2, with several other participants in both focus groups giving examples of the changes in clinical characteristics, such as ‘maternal age’ (Grace, Prisha, focus group 2), ‘obesity’ (Grace, focus group 2), ‘in vitro fertilisation treatment’ (Grace, focus group 2; Frances and Angelica, focus group 1) and ‘patients are sicker’ (Grace, focus group 2).
‘But one thing I see is assisted reproduction – massive amounts of [in vitro fertilisation]. Demographics have changed hugely. Maternal age.’
(Grace, focus group 2)
The knock-on effect of some comorbidities was explored and was a central theme throughout both focus groups. For example, the first focus group discussed the number of women requiring postnatal antibiotics.
‘And then, if you have like three women at the same time on intravenous antibiotics, that takes more time.’
(Angelica, focus group 1)
‘So, there are longer stays, they are on multiple antibiotics, babies are on antibiotics and observations. So, the workload…is heavy.’
(Frances, focus group 1)
With the number of women with gestational diabetes increasing, participants detailed the extra time needed for monitoring infant blood sugars. Additionally, more women experience hypertension.
‘When we were on nights one week, room one, four out of five babies were on sugars [glucose monitoring].’
(Melissa, focus group 2)
‘It's a direct result of the high-risk problems that they had at the point of delivery. So it's not something that we can fix in a day or two. Hypertension has to be monitored.’
(Grace, focus group 2)
Evolving roles: protocols and procedures
Participants discussed additional protocols, guidelines and policies introduced in recent years. For example, a significant number of women are now prescribed anti-coagulant medication compared to 10 years ago. Extra monitoring and medication administration and associated documentation was described as ‘exhausting’ (Lucy, focus group 1, all participants agreed), as participants discussed additional treatments women and babies now require.
‘Innohep [anti-coagulant injections]…introduced recently, just for the high-risk women…at least half of our ward are getting Innohep, nowadays, like, for 10 days.’
(Prisha, focus group 2)
Another component of increasing responsibilities was described as babies who were historically cared for in the neonatal intensive care unit, who are ‘all on postnatal wards now’ (Amelia, focus group 2).
‘Another big change that's come on the wards is the babies that we're minding. So, I would have come from neonates before I came to postnatal and any baby that was really under 36 weeks would have gone to the neonatal unit, and then also any baby that was under 2.5 kilos would have gone to the neonatal unit for the first 24 hours, any baby who had running low blood sugars would have gone to the unit. They're all on postnatal wards now.’
(Amelia, focus group 2)
As the discussion continued, midwives highlighted the extra monitoring required for babies on postnatal wards, which would have traditionally been undertaken in neonatal units.
And the sugars, how many low sugars are there? And the lights [to treat jaundice].’
(Angel, focus group 1)
A discussion arose about medications and tasks that doctors would have traditionally done, which are now the responsibility of the midwife because of an extension of their role. Midwives are paid an extra one-sixth of their standard rate for these tasks under a ‘transfer of tasks’ agreement. Some midwives described the extra work involved with these extra duties.
‘The cannulation, the intravenous medications, they used to be done by the doctors, now we are all doing it.’
(Angel, focus group 1)
Notwithstanding the time these clinical duties take, one participant acknowledged the extra salary midwives receive for these additional tasks, as it appeared from the conversation that not all of the participants were aware of the additional payments associated with these clinical tasks.
‘We are getting paid, we did, we get a time and a sixth every day.’
(Aisling, focus group 1)
Historical issues revisited: the two-tiered system
Discussion took place around the different care options chosen by women and how they impact the care received. Participants suggested that women are not often fully informed about the different options in order to make the decision that is right for them; they ‘don't even understand what they're buying in to’ (Grace, focus group 2). The current maternity care system was described as ‘fragmented’ (Grace, focus group 1) and as being a ‘two-tiered system’ (Aisling and Aadya, focus group 1). For women who choose private and semi-private care packages, health insurance was suggested as a contributing factor, on some occasions, in the number of nights these women stay in hospital. Opinions were put forward in terms of the impact of Irish health insurance policies on maternity care received.
‘…depending on their cover and depending whether their induction was less than 48 hours, they take two antenatal nights from them and they only have one night in the postnatal ward.’
(Frances, focus group 1)
Although, in recent years, women often prefer to go home early, participants explored their perspectives of some women's lack of readiness upon discharge because of insurance restrictions.
‘…sometimes, you are sending someone home because their [insurance] cover is up and they have to go home, and she could be someone who doesn't know how to feed the baby and I could have just provided a solution…Honestly, many times, I did feel guilty about that…but what can I do?’
(Aadya, focus group 2)
Women who live in certain geographical areas are eligible for the early transfer home scheme, where a community midwife visits the woman in their home for approximately 5 days postnatally. This service is not available for women who pay for semi-private and private care. Participants elaborated on the disadvantages of discharge dates being decided upon by insurance coverage rather than a woman's readiness.
‘Recently, we had a lady [public patient] who, it was her third or fourth baby, she had a normal delivery and she lived in the [early transfer home] area and she qualified for [early transfer home] and she got to stay for two days and a lovely, qualified midwife and her team went out to her. Then we had that lady…the forceps, 40-year-old, on her own, first baby, no family support or very elderly parents…and she was out the door after two days. That's not really fair, and they both lived in the same area. But this lady had come and paid her semi-private fee to the hospital, they got the same care in the hospital, but then it was just “off you go.”’
(Amelia, focus group 2)
Woman-centred care: women need more time
Against the backdrop of the changes in postnatal care delivery, what appeared unchanged was the ‘inspiration’(Angelica, focus group 1) and ‘passion’ (Kiara, focus group 2) all the participants displayed for providing woman-centred care. The love midwives and healthcare assistants had for their job was evident from conversations in both focus groups.
‘I think we are really privileged to be able to shape somebody's future experience of their baby or babies. So, when you see them walking out the door and you have a laugh with them…and you kind of think they are the moments that you are looking for, where people can just take a breath and go “everyone is here safe.”’
(Frances, focus group 2)
The biggest challenge to ‘job satisfaction’ (Aadya and Amelia, focus group 1) was when the midwives were unable to provide woman-centred care because of time constraints.
‘You feel like you are disappointing them.’
(Kate, focus group 1)
The participants explained that ‘the postnatal stay getting shorter’ (Caroline, focus group 1), staff shortages, and an increasing list of tasks to be completed before discharge result in occasions when ‘discharges are so rushed’ (Kate, focus group 1) and was described as sometimes being a tick-box exercise.
‘I have a long checklist to go through when someone's going home.’
(Jasmin, focus group 1)
The participants expressed their concern about the limited time they sometimes have to have a quality one-to-one conversation with women to help them prepare as parents for when they are discharged.
‘They are not even fit enough to listen to you yet. It's such a short time, they're still all quite weak about things.’
(Aadya, focus group 2)
Women being discharged early was also seen to cause a knock-on effect of women requiring readmission and increased phone calls from women following discharge, for issues such as ‘hypertension, mastitis’ (Prisha, focus group 2) and ‘wound infections’ (Kiara, focus group 2).
‘These are the women then that we get the phone calls from, and these are the women that are coming back.’
(Amelia, focus group 2)
Several participants displayed passion in their belief that women need more time for postnatal support and that postnatal care should be provided for everyone in the community for longer than the current few days offered.
‘We're going to have to provide community midwives to most women, I think, it's the way to go…as a community midwife if you know somebody is struggling, you will keep an eye on them, and you will watch over them for 5–10 days.’
(Grace, focus group 2)
A solution was explored in the second focus group to develop midwife-led postnatal support groups/classes in the community. This is where midwives can provide education on infant care and maternal health and provide women with the opportunity to be assessed for common postnatal complaints such as wound or breast issues. Also, women could provide support for each other.
‘If we had a way to do a postnatal class twice a week open to all women. So, one midwife or two midwives and a room here for 2 hours, so we have to send them home on a Monday, but there's a postnatal support group in here on a Tuesday and a Thursday, or on one day a week, but I think you catch a lot of people that would be…“this breast is a bit sore, there's a bit of a red mark here.”’
(Grace, focus group 2)
Discussion
Care during the fourth trimester, as it has come to be known (Mehta and Srinivas, 2021), should be given equal credence to antenatal and intrapartum care, to improve the quality of health for mothers and babies (Royal College of Midwives, 2014). This study's findings provided an in-depth exploration of the increasing clinical workload on postnatal wards over the past decade. To improve physical and psychological outcomes for new mothers, women should receive additional postnatal care. To achieve this, the number of community midwives needs to be increased nationally to provide all women with community midwifery care postnatally, regardless of their chosen care package or geographical location. Women should be visited in their home for up to 12 weeks postnatally, and postnatal clinics should be available for women to attend in the community. These suggestions mirror national and international recommendations (Begley et al, 2011; Barimani and Vikström, 2018; Goodwin et al, 2018). A key aspect of midwifery care recognises deviations from the expected norm in the postnatal period (Mason et al, 2001; Nursing and Midwifery Board of Ireland, 2016). A consequence of early postnatal hospital discharge is a limited time for relational and emotional care to assess women at risk for physical and psychological illness (Barimani and Vikström, 2018), as attested by the participants in the present study. A priority of the Maternity Strategy is to provide all women with safe, high-quality, and consistent woman-centred care (DoH, 2016). However, limited efforts have been made by Ireland's DoH to provide this care or choice to all women. As evidenced by the data from the present study, the consequence of early discharge with limited follow-up community midwifery care is an increase in readmission rates. Similarly, a Swedish study reported emergency department visits in 12% of new mothers in the first few weeks of childbirth as a result of breastfeeding or childbirth issues (Barimani and Vikström, 2018). An American study reported that nearly a quarter of women who gave birth in 2016 (n=149 563) accessed a health service with a health issue within the first 60 days postnatally (Steenland et al, 2021).
Findings from the literature highlight the stark differences between postnatal care services nationally and internationally. In New Zealand, mothers are visited by midwives 5–12 times during the first 6 weeks after birth (Schmied and Bick, 2014). Mothers in the Netherlands receive up to six visits by a midwife within the first 10–12 days following discharge (Wiegers, 2006). In the UK, the Royal College of Obstetricians and Gynecologists (2011) advises that women's standard length of care continues for up to 10 days post birth (Royal College of Midwives, 2014). The 5–7 day limit on community midwifery postnatal care offered to a small percentage of the Irish population is far inferior to other countries. Mehta and Srinivas (2021) recommend that the postnatal period should be more widely promoted as the fourth trimester of pregnancy and that this period should exceed 12 weeks. Care should be provided as an ongoing process, rather than as merely one or two brief encounters with different health professionals, offering no continuity of care (American College of Obstetrics and Gynecology, 2018; Mehta and Srinivas, 2021). Women should receive the opportunity for a complete and holistic visit with a healthcare professional, which should include assessing the woman's social, psychological and physical wellbeing, including infant care and feeding, mood and emotional wellbeing, sexual health and contraception, sleep and fatigue, chronic disease management, health maintenance and physical recovery from birth (American College of Obstetrics and Gynecology, 2018).
The latest Health Information and Quality Authority (2020) report highlighted difficulties in retaining and recruiting the midwifery staff required to provide safe maternity care in all maternity units in Ireland. Providing quality woman-centred care gave midwives and healthcare assistants in the present study immense job satisfaction, consistent with findings in other studies (Warmelink et al, 2015; Jarosova et al, 2016). However, midwives experience incredibly high rates of burnout, anxiety and stress compared to other professions (Creedy et al, 2017; Hunter et al, 2018) and not having time to build quality midwife–mother relationships increases the risk of burnout and decreases job satisfaction (Doherty and O'Brien, 2021). Healthcare worker burnout is associated with increased turnover (Lu and Gursoy, 2016) and sickness absence (Borritz et al, 2006). Therefore, the job satisfaction of Ireland's healthcare workforce needs to be strongly considered by policymakers to reduce attrition and long-term absence.
The COVID-19 pandemic has added to the stresses of maternity staff and the women in their care. During the focus groups, this crisis did not exist, so the effects of this type of crisis were, naturally, not discussed. Major reorganisation of obstetric services in the research site was swiftly and efficiently executed in response to the pandemic (Sheil and McAuliffe, 2021). Staff had to quickly adapt to the new requirements associated with these changes, and many were reallocated to different services (Sheil and McAuliffe, 2021). The COVID-19 crisis substantially increased stress levels for all healthcare workers who have been forced to work in unfamiliar surroundings. Midwives, as well as other healthcare workers, are in constant fear of becoming sick and spreading the virus to their family members (Kenny, 2020). A press release during the height of the first wave of the pandemic reported that over half of all COVID-19 cases in Ireland were healthcare workers (Irish Nurses and Midwives Organisation, 2020). Furthermore, with social distancing a top priority during this pandemic, midwives around the globe have reduced the amount of time spent face to face with the women in their care to avoid transmission, which unfortunately reduces the time for holistic care (Rodrigues Flores, 2020). The COVID-19 pandemic has had a detrimental impact on mental health internationally, with 80% of respondents in one global survey reporting feeling moderate to high distress related to COVID-19, as well as 63% reporting feeling depressed or anxious (Canady, 2020). Postnatal care in Ireland was affected, with some public health nurse visits becoming restricted or ceasing and many women have felt isolated because of limited social and professional support (Panda et al, 2021). Restrictions on visiting in postnatal wards had their benefits in terms of less traffic and more rest (Cullen et al, 2021). However, restrictions on birthing partner visitation caused upset and loneliness, and the lack of tangible assistance, which would normally be provided by the partner in the days after birth, was an issue for many women in the research site (Cullen et al, 2021) and created extra work for postnatal ward staff. Further research is required to explore the full extent of the long-term impacts of postnatal care for those who received this altered form of postnatal care during the pandemic.
The findings of this study need to be taken into context, as the study was undertaken in one maternity unit in Ireland, hence reducing the generalisability of the findings presented. However, this study adds to the existing research and provides an understanding of the challenges to providing postnatal care in Ireland.
Conclusions
This study explored midwives and healthcare assistants' experiences of providing postnatal care in the context of a maternity hospital in Ireland and strongly supports the urgent requirement for extended community midwifery postnatal care for all women for up to 6 weeks post birth. Although the birth rate has reduced over the past decade, the participants in this study described additional maternal comorbidities and clinical tasks in conjunction with decreased length of hospital stay. This was highlighted as placing extra strain on postnatal ward staff and reducing opportunities for quality woman-centred care. The findings also emphasised the fragmented and inconsistent postnatal care in the community, which limited follow-on midwifery support for large numbers of women nationally. Links to community midwifery care for all women will improve quality, individualised care and, in turn, maternal health and wellbeing in the postnatal period.
Key points
- Maternal comorbidities and caesarean section rates have increased, impacting the level of care required postnatally.
- Additional clinical protocols and a transfer of tasks from medics to midwives in recent years has increased midwifery duties, decreasing time for emotional care.
- A fragmented two-tiered maternity system in Ireland limits many women's care options for accessing postnatal community midwifery care after being discharged from hospital.
- Postnatally, shorter hospital stays limit women's time to receive quality woman-centred care, and reduces midwives' opportunities to assess women, physically and psychologically, increasing readmission rates and emergency after care.
- The postnatal period should be more widely referred to as the fourth trimester of pregnancy and community midwifery care should be available to all women in Ireland for at least 6 weeks postnatally.
CPD reflective questions
- What changes have you seen in care delivery in your unit over the past few years?
- Do you feel that postnatal care is adequate in your country?
- How do you feel postnatal care can be improved?
- How has decreased length of hospital stay impacted care delivery at home, postnatally?
- What do you think new mothers' experiences are of decreased hospital stay (with and/or without community midwifery care at home after discharge)?