The length of the postnatal hospital stay has fallen over the past 30 years, with pressure on health services to reduce this further (Bowers and Cheyne, 2016). With the emphasis on enhanced recovery, many women are now discharged home within 24 hours of giving birth, even after caesarean section (World Health Organization (WHO), 2013). Shortened hospital stays in the postnatal period have implications for maternal and neonatal outcomes; therefore good quality postnatal care is essential.
Surveys have found dissatisfaction with the provision of postnatal care, both among mothers and midwives (Bhavnani and Newburn, 2010; Royal College of Midwives (RCM), 2013; WHO, 2013). Midwives report particular challenges, including a lack of time at the postnatal hospital discharge to impart vital health information, such as hand hygiene and maintaining maternal wellbeing (RCM, 2013). The National Institute for Health and Care Excellence (NICE) (2013) outlines the myriad of information that mothers should receive at the first postnatal contact, and the postnatal hospital discharge requires women to have received this vital public health information and tailored advice (NICE, 2013). In addition, language barriers could further compound communication difficulties in women with low levels of spoken English. Evidence suggests that trained interpreters are not consistently used in maternity services (Haith-Cooper, 2014; Phillimore, 2015).
Hospital readmission
Unplanned maternal readmission to hospital within 42 days postpartum is an undesirable maternal outcome. In the year 2013–2014, the mean rate of emergency readmission following normal birth in England was 1.9% (3% following caesarean section) (Royal College of Obstetricians and Gynaecologists (RCOG), 2016). The definition of emergency maternal readmission has changed from 30 to 42 days and therefore a direct comparison is difficult to make; however, there appears to have been an increasing rate of maternal readmissions over the past 5-10 years (RCOG, 2013).
Infection continues to be one of the main reasons for postnatal hospital readmission and sepsis remains a significant cause of maternal death in the UK, with higher rates in women from black or minority ethnic groups (Acosta et al, 2014). Approximately 1 in 1000 women will develop sepsis (Knowles et al, 2015), and between 2011-2012 a study from the UK Obstetric Surveillance System (UKOSS) reported 365 women with sepsis, 5 of whom died (Acosta et al, 2014). For each death, approximately 50 women have life-threatening morbidity (Acosta et al, 2014). There is considerable variation in readmission rates between Trusts, which may depend on how well prepared women are at the postnatal hospital discharge, with advice including clear information regarding care of surgical wounds to prevent infection, for example (RCOG, 2013).
The postnatal hospital discharge process
A systematic literature review revealed a lack of information regarding what constitutes the essential elements of the postnatal hospital discharge process (Bick et al, 2011a). Providing simple public health messages to help prevent sepsis and reduce maternal morbidity is an example of advice required at the postnatal hospital discharge; therefore this study sought to explore perceptions of the postnatal hospital discharge the advice and information offered among women and student midwives, in particular relating to postnatal maternal sepsis prevention.
Methods
An interpretivist tradition was adopted to understand how women and senior student midwives made sense of the postnatal hospital discharge and the meaning they attached to it (Topping, 2010). This involved a hermeneutic phenomenological approach (Todres and Holloway, 2010), which sought to understand the lived experiences of both student midwives and women.
A purposive sample of participants was recruited and included the following:
This was to ensure a broad socioeconomic, ethnic and cultural background of the participants
Three focus groups were undertaken, lasting an hour each. These provided the opportunity to explore in depth how the postnatal hospital discharge was conceptualised and negotiated by the participants (Mason, 2005). Questions focused on the postnatal discharge in general and then more specifically on sepsis advice and information that the participants had seen provided or had received (Box 1). The focus groups were audio recorded and transcribed verbatim by a professional external agency. Refreshments were provided and the women reimbursed for their travel
Ethical issues
Ethical approval was obtained from the University of Bradford Ethics Panel. Women attending the NCT groups who expressed an interest had their contact number taken by the group facilitator. They received an information sheet and were phoned by the principal investigator. English language ability was assessed by the NCT researcher, who was also experienced in working with women with language barriers. No women required an interpreter. Student midwives received an information sheet and explanation in class and emailed a researcher if they wished to participate.
Informed consent was gained at the beginning of the interviews. This was written consent for the student midwives and members of the first women's focus group. Verbal, audio-recorded consent was gained from the vulnerable migrant women, in case they feared providing a signature due to concerns about whether it would have had an effect on their immigration status. Anonymity and confidentiality were assured and requested by participants. Participants were advised to avoid recalling personal specific care experiences that may reveal substandard care, as if this occurred, the midwife researcher could have a conflict of interest between her role as a researcher and that of a health professional. Such revelations could have led to a dilemma as to whether the research process should continue or be terminated and could also have implications for confidentiality and obligations to report examples of bad practice.
For the migrant women, it was stressed that the researchers had no link with the Home Office and that the data would only be used for research purposes. There was potential for participants to become stressed or upset during the focus groups for an unconnected or unforeseen reason; therefore, participants were advised that they could withdraw from the focus group and receive a debrief from the NCT researcher. Participants who withdrew were also offerd the option to be signposted to relevant support services. such as third sector counselling. Participants were informed that they could withdraw their consent within one week of the focus group. Transcripts were stored in a password-protected computer file accessible only to the researchers and transcribers and once transcribed, audio recordings were destroyed.
Data analysis
The data were subject to thematic analysis (Braun and Clarke, 2006). This was undertaken by hand, using Microsoft Word and on screen colour-coding. This involved reading and re-reading the transcripts, then coding the data and grouping codes together to form themes. To ensure rigour, the themes were discussed by the research team to ensure they were true to the data.
Findings
Three key themes emerged from the data: ‘It's all a rush’, ‘too much to remember’ and ‘a lack of consistency’. The transcribers could not differentiate individual contributions so the findings are classified by interview order for the women's contributions, i.e. W1 or W2 for the women's focus groups and StMW for the focus group held with student midwives.
‘It's all a rush’
Rushing was a concept discussed in all three interviews and this was felt to affect the quality of the information provided or received at the postnatal hospital discharge. Rushing was felt to be an issue related to the midwife undertaking the discharge process:
‘My midwife, she's just in hurry, she just ask quick, quick, quick question and say, “okay, you are good… you can go home”’
This led to concerns that the midwives were not providing all the information needed.
‘But it means it's all a rush and you think, “what if they missed something?”’
Midwives rushing was also acknowledged as an issue by the student midwives:
‘There's so much, and when you're rushing doing a discharge and you're trying to get TTOs [‘to take out’, i.e. hospital discharge prescriptions] together and all the rest of it.’
Women believed that midwives were rushing because they needed the bed quickly for the next woman and commented that they felt part of a ‘standard, conveyor belt process.’
‘It felt like it was quite standard that everybody's out at a certain time ready for the next lot to come, that's … I felt like it was like a hotel checkout, everybody was flying out.’
The concept of rushing was not believed to be entirely midwife-led. Some women felt that midwives took their time but the women just wanted to get home quickly and consequently did not take advantage of the information provided at the discharge:
‘I was rushing it because I just wanted to go … [I answered] “Yes” to every question, “okay, brilliant, yeah, go, go, go,” but I don't think the person doing it was rushing at all, so that was good.’
Women wanting to go home quickly was frequently blamed by women and some student midwives on delays to the hospital discharge process. Women commented that they had to wait until late in the day to be seen by a midwife, then had lost interest in the information provided by this point.
‘Too much to remember’
What was said at the postnatal hospital discharge formed a large part of the discussion, both in terms of general information provided and sepsis prevention advice specifically. It was generally agreed that there was too much verbal information to remember specific details; however, there were specific topics that women did remember being discussed; most frequently relating to contraception and breastfeeding. No participants recalled a conversation specifically around sepsis prevention, and many participants stated that they had never heard of it. Infection was a concept of which women were aware; however, women could not recall infection prevention being discussed at discharge. Conversely, some student midwives felt that this was discussed with women.
‘I have heard people say “infection postnatal can happen really, really quickly and it's imperative that you do ring us straightaway” but not everybody would do that.’
Women and student midwives could recall specific advice that would be given to prevent infection, such as handwashing, personal hygiene, wound care and frequently changing sanitary pads. However, the women did not appear to appreciate the link between this and preventing sepsis. They also did not seem to understand when to be concerned about whether their wound may be infected or the general symptoms to watch out for.
‘I didn't realise this happen also with the women, they get infected with this, because I also got stitches and they say it's going to be dissolved a few days and I don't, because I was getting pain and that whenever I sit and hold my baby because I was trying to give him breastfeeding but I didn't realise it was going to harmful for me also.’
Similarly, the student midwives acknowledged that the advice given was not provided in the context of sepsis prevention and that they didn't believe enough information was provided to prevent sepsis at the postnatal discharge.
‘A lack of consistency’
A lack of consistent information was discussed at all the focus groups, and related to how the information was provided, what was provided and when it was provided.
Discussions on this lack of consistency included the use of leaflets, and it was reported that some midwives verbally provided key messages with leaflets for women to read later to reinforce the message. Other women reported not receiving verbal messages but being provided with too many leaflets to read at home; most of which were not read or the content not remembered.
No women could recall receiving a leaflet about sepsis (or infection) prevention, symptoms or advice.
‘So many leaflets and so many advice and information but I don't remember exactly about this.’
One student midwife had sourced a leaflet about sepsis prevention, although none of the other student midwife had seen this.
Another area of inconsistency at the hospital discharge was overcoming language barriers when giving information and advice, which was discussed by student midwives. Some had seen a professional interpreter used; however, other students found that midwives appeared to rely on relatives to communicate the information.
‘It's normally a younger sister or, like, her equivalent. I've seen they … mostly they would pass the information onto female relatives and it tends to be sort of like the second … generation, so a female relative, so they maybe were born in the UK and are native speakers … you can get the closest to that you can get really.’
However, difficulties were experienced with women who were not supported by an extended family with English speaking relatives.
‘Within the Asian culture they often have a lot of family members around them and you can give that information to them but I've noticed with eastern European women, for instance, they're often there with just a husband and he might not speak English either and then you're really stuffed and what do you do? You do your best and you're waving your hands around but how much of that information is actually going in, you just have no way of knowing.’
The consistency of the translation was another aspect discussed by the student midwives when relying on relatives to interpret at the postnatal hospital discharge.
‘The strength of the translation is in the truth of the translator … if you give the information to a relative, they might think that they know what you mean and just sort of shorten it.’
Telephone interpreting services were discussed, but they were rarely used due to the cost and the time taken to organise the phone call.
‘When you're under pressure and then, like, when a discharge doing and the woman wants to go home … I've seen people be like, “well, we could go get it, but that'll take another half an hour, hour plus, so what we'll do is we'll do our best.”’
In addition, focus group discussions revealed that women who experienced language barriers were generally only provided leaflets written in English:
‘But they're not offered any written information that they can understand themselves either, so it is, it is inadequate isn't it?’
Inconsistency also related to the way that sepsis was (or was not) talked about at the postnatal discharge. Language use appeared to vary and the participants expressed concern that the seriousness of the condition was played down when it was discussed:
‘But I think I didn't know that sepsis was, like, such a big killer and things like that, so I think if they opened with that, it would stick more because you're more: “oh, this is a real problem.”’
In addition, the words used to describe sepsis were inconsistent, with some women being informed they may just experience flu-like symptoms. Other women were told that they may have a localised infection or feel under the weather. The words ‘blood poisoning’ was not generally used. One student midwife blamed this inconsistency on changes to terminology over time:
‘People used to talk about septicaemia and they understood that as a very serious disease and that terms seems to have gone out the window, and healthcare professionals understand what sepsis is and talk about it all the time, but the general population isn't hearing sepsis, septicaemia, they're just hearing infection, oh an infection's alright, that's just like having a whitlow or something.’
The final discussion around lack of consistency related to the timing of sepsis advice. Participants discussed how the advice that they were given around infection or sepsis was provided at different points in the maternity journey. This ranged from the booking appointment up until the first or second home postnatal visit rather than at the postnatal hospital discharge.
‘I've seen it more, yeah, done in community which is sometimes too late … it should be done at discharge, yeah.’
Discussion
This study confirms that both women and student midwives experience difficulties with the postnatal hospital discharge process. The quality of advice and information received is negatively affected by midwives rushing to get the woman discharged, and/or the woman rushing to go home. In addition, having too much information to impart or remember, and inconsistencies in the ways the information being imparted was also perceived to influence the quality of the postnatal hospital discharge process. These findings add to the limited evidence around hospital postnatal care (Bhavnani and Newburn, 2010; Bick et al, 2011b; RCM, 2013; WHO, 2013), where midwives were perceived to be rushing due to staff shortages. The NCT survey found that this led to delays in women going home, and that some women had self-discharged in frustration at having to wait for a midwife to undertake the postnatal hospital discharge process (Bhavnani and Newburn, 2010).
This study also found that, in some areas, trained interpreters were not used at the postnatal hospital discharge, and that there was an over-reliance on family members to interpret for the woman. This supports previous studies, which have found that the use of interpreters in maternity care is patchy (Haith-Cooper, 2014; Phillimore, 2015). It is concerning that family members are still relied upon, when previous work has highlighted problems such as potential translation errors (Dysart-Gale, 2007) and breach of confidentiality (Meddings and Haith-Cooper, 2008).
This study is limited, with a small, local sample of women obtained from two specific postnatal forums, and no women requiring an interpreter. If women with language barriers had been included in the study, it may have been revealed how these affected the experience of the postnatal hospital discharge; however, the women and student midwives represented postnatal experiences from four different NHS Trusts, which increases the likelihood that these findings are transferable to other NHS sites. In addition, no other research could be found focusing on the postnatal hospital discharge, and specifically the advice provided to prevent maternal sepsis.
It would appear that more specific information is required at the postnatal hospital discharge, to prevent maternal sepsis. This includes providing the information in a timely manner to ensure women's interest is not lost. This information would need to include advice about prevention, early symptoms and who to contact if the woman develops symptoms of sepsis. Using the term ‘sepsis’ rather than ‘infection’, and explaining what this is, could help to re-enforce the importance of the advice offered. As this information needs to be provided in a time-efficient and consistent way, in the woman's spoken language, innovative approaches to impart the information could be developed, perhaps using digital technology. More research is needed to test whether this would be a feasible approach and whether using health technology could result in a reduced incidence of postnatal sepsis in women.
Conclusions
The postnatal hospital discharge process is an important transition and its quality can affect the risk of maternal and neonatal morbidity. However, there is little research focusing specifically on the postnatal hospital discharge process. This study found that student midwives and women believed that the discharge process was rushed, with too much information provided. The advice offered around maternal sepsis prevention was inconsistent and the use of interpreters patchy. With increasing budget cuts in the NHS and a chronic shortage of midwives, it is necessary to consider the development of time saving, innovative ways of presenting information, such as using digital technology. Any technology would need to thoroughly tested in practice, but an improvement in the postnatal discharge process could contribute to the reduction of sepsis in postnatal women.