Following the publication of studies of maternal morbidity, questions were raised about whether routine universal provision of postnatal care could enhance maternal health outcomes and what revisions to care would be necessary to achieve this (MacArthur 1999). Randomised con-trolled trials (RCTs) undertaken in the United Kingdom and Australia assessed the impact on maternal physical and psychological health of revisions to routine care or an intervention in addition to routine care (see Table 2.1); however, only the RCT by MacArthur et al. (2002, 2003) had a positive benefit as described later. RCTs of antenatal or postnatal interventions for women at risk of specific postnatal health problems (i.e. prevention of post-traumatic stress disorder) are not included here.
Midwifery-led postnatal care
The intervention assessed in the RCT by MacArthur et al. (2002, 2003) was a package of care delivered by midwives. The unit of randomi-sation was the general practice. The trial took place across the West Midlands of England and included general practices from rural, urban and inner city areas. The focus of the new model was provision of planned visits over an extended period of time, tailored to women’s individual needs with a focus on the identification and management of common health problems. Each woman received a first home visit, a visit at around 10 days and 28 days and a final visit at 10–12 weeks, which replaced the routine GP 6–8 week check. All other visits were to be based on need and not routine, informed by a care plan. Symptom checklists were to be used to identify problems, with evidence-based guidelines for midwives to implement first-line management of those
Table 2.1 Randomised controlled trials of revisions to usual care to enhance maternal postnatal health.
Authors Intervention Outcomes Findings
Turnbullet al . (1996) (UK), Shieldset al . (1997)
Midwife managed antenatal and intrapartum care (n= 648) compared with usual care (n= 651). Named midwife to lead care.
No additions to routine postnatal care
Obstetric intervention (P)
Fewer antenatal complications (hypertension, haemorrhage), fewer episiotomies, No differences in perineal tears. Birth
complications similar, no differences in foetal or neonatal outcomes, EPDS score lower among intervention group
Maternal health at 7 weeks (S):
EPDS; views of care; satisfaction with care
Gunnet al . (1998) (Australia)
683 women randomised to early (1 week) postnatal GP visit or usual (6 week) visit, No change to content of visit
EPDS, SF36 at 3 and 6 months (P), breastfeeding, number of problems,
satisfaction with GP care (S)
No differences in outcomes. Women randomised to early visit were less likely to attend, more likely to report breastfeeding problems, problems with adjustment to motherhood and less likely to have vaginal examination
Morrellet al . (2000) (UK)
Costs and benefits of postnatal support workers. Up to 10, 3-hour visits by support worker in first 28 days (n = 311) compared with usual care (n= 312)
General health perception domain of SF36 (P). EPDS, Dukes Functional Support Score, breastfeeding (S) at 6 weeks and 6 months
No difference in any health outcomes.
Women’s satisfaction with support workers higher than for all other services. No savings to NHS
Reidet al . (2002) (UK)
2× 2 factorial trial, community setting.
1004 women
randomised – 1. Local support group with facilitator starting 2 weeks post-birth 2.
Postnatal handbook posted at 2 weeks post-birth
EPDS score at 3 and 6 months (P)
Low uptake of support group. No differences in EPDS, SF36 or SSQ6. Women had favourable opinions of the postnatal
handbook SF36, SSQ6,
women’s views of care at 2 weeks, 3 and 6 months (S)
Table 2.1 (continued )
Authors Intervention Outcomes Findings
MacArthur et al . (2002, 2003) (UK)
Cluster RCT of new model of midwifery-led care (n= 1087 from 17 GP practices) compared with current care (n= 977 from 19 GP practices) Planned midwife visits, symptom checklists at 10 and 28 days, guidelines for management, midwifery care extended to include final check at 10–12 weeks
EPDS scores, mental health domain (MCS) and physical health domain (PCS) of SF36 at 4 and 12 months (P)
Significant difference in EPDS and MCS scores at 4 and 12 months. No difference in physical outcomes. Women’s views of care more positive or did not differ. Intervention care was cost-effective Breastfeeding,
maternal morbidity at 12 months, women’s opinions of care, health professionals views of care (S)
(P)= primary outcome and (S) = secondary outcome
identified. A total of 1087 women were recruited from 17 general practices randomised to the intervention and 977 from 19 general practices, which formed the control group.
Main trial outcomes were the Edinburgh Postnatal Depression Scale (Cox et al. 1987), with a score of≥13 or higher taken as an indication that a woman was likely to be depressed, and the Mental Health Component Score (MCS) and Physical Health Component Score (PCS) of the SF36, a measure of general health and well-being. The outcome measures were included in a postal questionnaire sent at 4 and 12 months after the birth.
Questions on maternal health problems were included in the 12-month questionnaire. Breastfeeding duration was assessed at both time points and ‘good’ practice indicators such as uptake of infant immunisation were assessed using GP records at 12 months after the birth. A range of process outcome data was also collected to enable the study team to assess if implementation of the new model took place (and which elements were more or less likely to be implemented) and to compare the number of midwifery visits made in the two trial groups for the cost-effectiveness analysis. Women were also asked to keep a diary to record which health professionals had visited them during the postnatal period.
The results showed a significant difference in maternal mental health outcomes at 4 and 12 months after the birth (MacArthur et al. 2002, 2003).
The distribution of the mean MCS scores by cluster (general practice)
showed that the results were general and could not be attributed to one or two clusters with more extreme scores. This was also the case for EPDS scores. There were no differences in PCS scores at either time point. The secondary outcomes that included women’s views of care were either significantly more positive in the new model or did not differ between the trial groups. Maternal health problems at 12 months, which were also a secondary outcome, showed significant differences in depression, haemorrhoids and fatigue, which were less likely to be reported by women who received the new model of care, with no difference in breastfeeding outcomes. Women who received the new model of care were less likely to visit their GP during the first year after the index birth about a subsequent pregnancy, and immunisation uptake for the study group showed a 98% uptake. The care provided within the new model was cost-effective as health outcomes were better and costs did not differ substantially.
To date, this is the only trial to have shown a significant effect on maternal postnatal health but only on psychological and not physi-cal health outcomes. Reasons for this could include the difficulty of completely resolving a physical symptom, such as backache or urinary stress incontinence. However, the positive impact on mental health that acknowledgement of a physical symptom could have is also an impor-tant consideration. It is also plausible that women who had planned care from a midwife they knew over a longer period of time enabled them to more freely discuss their health.
The trial findings demonstrated for the first time the impact mid-wives could make to public health from revisions to routine care. The researchers concluded that adaptation of the new model into National Health Service (NHS) care as standard was justified; however, no fur-ther work has been undertaken to evaluate if the new model could be implemented outside of a RCT and achieve the same health benefits.
Elements of the ‘package’ of care have been reflected in recent policy such as the National Service Framework for Children, Young People and Maternity Services (DoH 2004) and National Institute for Health and Clinical Excellence (NICE) guidance on routine postnatal care (NICE 2006) but whether this ‘piecemeal’ approach to postnatal care revision can achieve the same anticipated psychological health benefits is as yet unknown. The next section of this chapter considers recent policy and practice developments for contemporary midwifery postnatal care.