scenario, there are risks that not only will care lack sensitivity, so that women’s feelings may be overlooked, but it may also fail to observe significant physical health problems.
The patterns of postnatal care from midwives differ widely across different countries. In the United Kingdom, home visiting by midwives has been long established, and women expect to receive support at home from midwives, for 10 days, or sometimes for up to 28 days (Department of Health 2004, 2007). This is also followed by an initial home visit by a health visitor, following which women may attend community-based clinics for health checks, immunisations and advice on baby care. This is in contrast to some Western countries, such as the United States, where domiciliary care is not the norm and not universally provided. A number of studies of postnatal support in the United States, therefore, are based on limited schemes targeted towards families or mothers in particular risk categories, and these have varied widely in their effectiveness (Bennett et al. 2007). In some European countries the need to further discuss and specify the aims of postnatal care, taking into account the challenge of providing high-quality care after childbirth, is discussed in the light of a development characterised by a continuous reduction in the length of hospital stay, in combination with increasing public demands for information and individualised care (Vendittelli et al. 2005; Rudman & Waldenstr ¨om 2007; Carlgren &
Berg 2008).
Similar to the United Kingdom and other high-income countries, length of stay in hospital after birth has declined over the last decade, but levels of home-based postnatal support by professionals have not increased as a result, meaning that hospital-based midwives are providing care for a rapid turnover of women, with little time to get to know their needs or provide support, and community-based midwives have less time available for each postnatal visit. Although ‘selective visiting’ according to women’s needs is encouraged in national policy in the United Kingdom, in practice, the pattern may often depend more on practical considerations than the assessment of each woman’s needs and wishes (Beake et al. 2005).
Levels and types of informal support – from family, neighbourhoods and friends – also vary in different cultural and social settings as well as for different individuals. Examples from two qualitative studies in the United Kingdom can illustrate this. The first involved interviews with a diverse sample of women who had given birth in a London teaching hospital, using a narrative approach to recount their maternity experience and views (Beake et al. 2005). The women in this study, and in the wider survey of which they formed a sample (McCourt &
Beake 2001), were more critical of postnatal care in hospital than in any other aspect of care. They felt that their ordinary needs for practical,
emotional and informational support were not being met and some women spoke of feeling abandoned on the postnatal wards:
I kept asking for help with feeding but nobody would come and if they did it was like about a minute and then the next day somebody said ‘do you want to go home’.
The quality of the support received was also a matter of concern, as some women also reported feeling undermined by midwives’ responses to their needs for help. In hospital, women are particularly dependent on professional support as they are in the early stage of recovering from the birth, and they are relatively isolated from the informal support that their partners, family and friends might provide. Additionally, women may lack experience of new babies and need information and reassurance as well as practical help. This woman, for example, was upset by a midwife’s response to her request for help for what clearly, to the midwife, seemed a trivial issue:
so (first baby) had all this black stuff that comes out after the baby comes into the world, like pooh, but it is so horrid and I was terrified because it was so much. . . I rang the bell, it was 3 o’ clock. I said
‘look at this’. She said ‘so, (shouting tone) she was expecting to have this, are you calling me just for this, just change the nappy and go back to bed’ and walked out of the room.
It is easy for midwives to forget that what seems routine and unim-portant to them may feel very different for a mother struggling to adjust to caring for a new baby while also recovering from giving birth. In contrast, those women who felt they had been given support appreci-ated this greatly. The woman quoted below felt she had a lot of help following her Caesarean birth, including taking the baby at night when crying so that she could rest. She was also more positive about the midwives’ attitudes:
having 24 hour a day somebody who knows what they are talking about and can talk to you in a way that you can understand and appreciate. None of them ever lost their cool or anything, even though you could see they were busy.
The women’s views of postnatal care at home were more positive and they appreciated the availability of midwives to visit at home, but they often found the care to be routine and rushed, with the result that more time-consuming issues such as breastfeeding problems or feelings of low mood and difficulty in coping could not be attended to sufficiently (Beake et al. 2005).
The second study we refer to involved interviews, using a similar approach, with a sample of women in a neighbourhood with a high proportion of South Asian women and other minority ethnic groups (McCourt et al. 2006b). The majority of the respondents were South Asian women of Indian origin. These women held very similar views of hospital postnatal care, for example:
After the birth I did not have any help at all until I came home.
One midwife (from the community group practice) came to check the baby. She did remove the stitches and done everything. The hospital people, some really don’t know what they are doing. There is no communication with each other. They are not doing a good service, they don’t really care enough about people.
Most lived within extended families or had relatives living nearby and reported that they had plenty of practical support at home. They did not have the same reliance on professionals for practical or emotional support, and those who were not born in the United Kingdom explained that such professional support would not have been available in their home country. Nonetheless, they felt strongly that such support should be available, as professionals cannot assume that women have good informal support, and because they have particular expertise and infor-mation to offer, for example, in dealing with breastfeeding problems:
The midwife tells us to do it in a certain way and she will say ‘if you do it that way you get back pain’ so it’s things like that which is helpful. Even our parents don’t know all about this.
From the above discussion, it is clear that even women who have a healthy pregnancy and straightforward birth commonly experience a number of difficult postnatal symptoms and may find the challenges of caring for a new baby exhausting and difficult, as well as rewarding and joyful. For an increasing proportion of women, worldwide, they commence their new lives with their baby following a difficult or even traumatic birth, or in difficult social circumstances and many lack good sources of ordinary support, increasing their reliance on professionals to cope with the early days of recovery and adjustment (McCourt 2006). The evidence from women’s views suggests that their post-partum physical, emotional and psychological health needs are not being fully addressed by current practice, which tends to include routine observations and examinations that are often unnecessary (MacArthur et al. 2003). Studies describing women’s experience of staff attitudes in early postnatal care show that often women felt poorly prepared for the postnatal period, needed more information about their own health and
complained of the lack of support, and that they were also critical about the inconsistency of advice and the lack of evidence-based and realistic information (Beake et al. 2005).
This suggests that midwifery care is very much a balancing act. It is important for midwives to not only be able to recognise morbidity and respond appropriately, giving enough care and support, and referring for medical care when appropriate, but also to avoid pathologising common postnatal problems, and encourage women to use their own, informal sources of support. Midwives also need to reassure women by letting them know that some health problems and difficulties are
‘normal’ in the sense of being frequently experienced after childbirth, and supporting them where possible to take up ordinary sources of support, such as, help from friends, neighbours and family so that they can rest and recover. In the following sections we look in more depth at three aspects of postnatal care that studies have shown to be important, but often overlooked in practice: perineal care, post Caesarean care and support for women with mental health problems such as post-traumatic stress following childbirth.