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‘What is could indeed be better’—Swedish women’s perceptions of early postnatal care
Midwifery 27 (2011) 737–744
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‘What is could indeed be better’—Swedish women’s perceptions of early postnatal care ¨ Ingegerd M. Hildingsson, RN, RM, PhD (Associate Professor)a,n, Ann-Kristin Sandin-Bojo, RN, RM, PhD (Senior Lecturer)b a b
Department of Health Sciences, Mid Sweden University, SE-851 70 Sundsvall, Sweden Division for Health and Caring Sciences, Karlstad University, SE 651 88 Karlstad, Sweden
a r t i c l e in fo
abstract
Article history: Received 15 January 2010 Received in revised form 7 April 2010 Accepted 11 April 2010
Background: studies have shown that women are more likely to be satisfied with intrapartum rather than postpartum care. The structure and organisation of care seems to be a barrier to good-quality postpartum treatment Objective: to explore the perceived reality and the subjective importance of early postnatal care provided in hospital, and to study women’s satisfaction with different models of early postnatal care and the factors that are most strongly associated with being ‘very satisfied’ with the postnatal care received. Method: a regional survey was conducted with 1240 women recruited in mid-pregnancy and followed-up two months after childbirth. Results: a statistically significant difference existed between the subjective importance and the perceived reality for all studied variables, with a greater subjective importance than perceived reality for all statements. The length of postnatal stay and the content of care were related to satisfaction, while the model of postnatal care was not. The most important variables for being ‘very satisfied’ with postnatal care were that the infant received the best possible check-ups/medical care, and that the woman received sufficient support from staff. Conclusion: further studies are needed to assess the best model of postnatal care that gives the best opportunities to provide satisfactory care for women and their families. & 2010 Elsevier Ltd. All rights reserved.
Keywords: Postnatal care Quality assessment
Introduction Contemporary postnatal care in most Western countries is characterised by a short length of stay (Brown et al., 2002; Hildingsson and Thomas, 2007), information intense content (McLachlan et al., 2007) and high parental responsibility in the care of the newborn infant (Hildingsson, 2007; Rudman and ¨ Waldenstrom, 2007; Hildingsson et al., 2009). Barriers to satisfaction of postpartum care have been linked to the structure and organisation of care. In a state-wide review of postnatal care in Australian hospitals, caregivers identified hindrances such as lack of continuity of care and the length of postnatal stay (Forster et al., 2005; McLachlan et al., 2007). Caregivers reported that there was limited time available to spend with women and further indicated problems with staffing (Forster et al., 2006; Rayner et al., 2008). Given the problems identified with postnatal care, different authors have suggested that individualised care, continuity of care and a flexible length of
n
Corresponding author. E-mail address: [email protected] (I.M. Hildingsson).
0266-6138/$ - see front matter & 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.midw.2010.04.007
stay could enhance satisfaction with postnatal care (Hildingsson, 2007; Hildingsson and Thomas, 2007; Lindberg et al., 2008; Rayner et al., 2008). During the last 10–15 years, new models of early postnatal care such as early discharge and family suites have been introduced as alternatives to traditional postnatal care. Team ¨ et al., 2000; Spurgeon et al., 2001) and midwifery (Waldenstrom family suites (Ellberg et al., 2006) increased the women’s satisfaction with their postnatal care. In addition to increased ¨ et al., 2006), family satisfaction (Ellberg et al., 2006; Waldenstrom suites/hotel wards seem to be a safe alternative in terms of re-admission (Ellberg et al., 2005). An Australian survey showed no association between early discharge, length of breast feeding and maternal depression (Brown et al., 2004). The content of early postnatal care has shifted throughout the years. Medical care and physical examinations of the woman after childbirth have, in some countries, diminished in favour of attention to the newborn (Hildingsson, 2007), but are still conducted in postnatal wards in other countries (McLachlan et al., 2007). Medical check-ups of the infant are one of the most valued and important care activities during pregnancy (Hildingsson et al., 2001), labour and birth (Sandin-Bojo¨ et al.,
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2008; Sandin-Bojo¨ et al., in press) and after childbirth (Hildingsson, 2007). Most studies on satisfaction with care during birth or after birth have identified areas that could be improved, such as ¨ father’s ability to stay overnight (Waldenstrom et al., 2006; Hildingsson, 2007; Ellberg et al., 2008; Hildingsson et al., 2009) ¨ and support from staff (Brown et al., 2005; Waldenstrom et al., 2006; Hildingsson, 2007; Ellberg et al., 2008; Hildingsson et al., 2009). When measuring women’s satisfaction with care, there are a number of methodological considerations. For example, the time point of investigation where it has been shown that satisfaction should not be measured too close to the birth but close enough for accurate recall (Bramadat and Driedger, 1993). Another issue is the dichotomisation of variables. Carr-Hill (1992) and Brown and Lumley (1997) suggested that all levels but being ‘very satisfied’ should be considered as sub optimal care. There is also a problem, as several researchers have previously indicated (Bluff and Holloway, 1994; van Teijlingen et al., 2003; Hundley and Ryan, 2004), that when questioned about quality and satisfaction with care during and after birth, there is a tendency for women to prefer the care they are familiar with, i.e. ‘what is, is best’. However, a recent study of intrapartal care measuring both the actually received care (perceived reality) and the subjective importance that women ascribed to the care showed that ‘what is, could be better’ (Sandin-Bojo¨ et al., in press). Patient satisfaction surveys are often the means utilised to evaluate experiences, e.g. the perceived reality of given care, but less often the subjective importance of the care received. A literature review by Sitzia and Wood (1997) identified the following different purposes for satisfaction measurements: to describe health-care services from the patient’s perspective; to assess the ‘process’ of care, identify problem areas and possible solutions; and to evaluate care. The objective of this study was to explore the perceived reality and the subjective importance of early postnatal care provided in hospital, and to study women’s satisfaction with different models of early postnatal care and the factors that are most strongly associated with being ‘very satisfied’ with postnatal care
Method This cross-sectional population-based study is one part of a regional prospective longitudinal survey of parents recruited in mid-pregnancy and followed-up in late pregnancy, two months and one year after childbirth. For the purpose of this specific paper, women who completed the third questionnaire two months after birth are included. The context of care in Sweden Midwives are the primary caregivers for women during prenatal care, birth and the early postnatal period in hospitals. Women with complications are treated by midwives in collaboration with their medical colleagues. Midwives perform all births with the exception of instrumental vaginal births and caesarean sections. Almost all care in Sweden is financed by the public health sector through taxes. Swedish midwives usually work in either community based prenatal care health clinics or in hospitals. In some cases, they may rotate between the labour ward and the postnatal ward. The average postnatal stay in hospital is two days (Swedish National Board of Health and Welfare, 2008). In some areas, midwives make home visits after discharge. Postnatal wards are usually staffed by midwives and enrolled nurses.
Models of postnatal care At the time of the investigation, there were four models of postnatal care available in the region: traditional postnatal ward, early discharge (from six hours after birth), co-care at the neonatal intensive care unit (NICU) and family suites on a patient hotel ward. Traditional ward and early discharge were available at all hospitals, but the hospitals had different approaches to postnatal care. In the largest hospital (with 1600 births/year), healthy mothers were not allowed to stay in the postnatal ward, but were recommended to either use the early discharge option or to have their postnatal stay in the hotel ward. In the smaller hospitals, all women had their early postnatal care in traditional postnatal wards or used early discharge. All hospitals have an NICU where parents could sometimes have co-care of the newborn, which meant that parents would be accommodated with their newborns. If all co-care rooms were occupied, women stayed in the postnatal ward or the hotel ward at night and made visits to the NICU at any time. Midwives from the postnatal ward also made visits to the NICU once or twice a day to care for the mother. In the NICU, partners were allowed to stay overnight in certain family rooms for co-care. Family suites in the hotel ward were introduced in the largest hospital two years prior to the investigation. The hotel ward is located in the hospital. Women with uncomplicated births and their partners can use the hotel option for postnatal care. From an administrative standpoint, the mother and the infant have been discharged when staying in the hotel ward. The hotel ward is staffed with a midwife during the day, but if problems occur during the night, parents call the traditional postnatal ward for help. Every morning, the midwife on duty at the hotel ward makes a telephone call to the parents to see if they need or want a visit. Otherwise, the parents are left alone to care for and bond with their infant. The midwives on the hotel ward also arrange revisits to the paediatrician for all parents and infants who took advantage of early discharge. In addition, they sometimes make home visits. The main reason for introducing this model of care was financial. The parents living in the region were free to choose a hospital. All women were informed about the different models of postnatal care by their antenatal midwife, and women’s preferences for postnatal care were usually written in the electronic records used during pregnancy, birth and postnatally.
Recruitment In 2007, women who were listed for a routine ultrasound at three hospitals in a county in the middle-north part of Sweden were invited to participate in a longitudinal study. There are seven municipalities in the county and three hospitals, of which one is a tertiary hospital with 1600 births annually; the other two are small community hospitals with 500 and 350 births, respectively. The ultrasound examination appointment was considered to be the best option to reach as many prospective parents as possible, due to the high attendance rate. Ultrasound examinations are routinely performed during weeks 17 19 in the pregnancy and are attended by the majority of women (Hagenfeldt et al., 1998). Occasionally, women chose not to have an ultrasound examination. Letters of invitation were sent two weeks prior to the screening appointment. Only Swedish-speaking women with a normal ultrasound examination were approached. After the ultrasound examination, the midwife in charge of the examination asked the women if they were willing to participate in the study. The women signed a consent form and were given the first questionnaire at the ultrasound ward, where they were asked to complete the form and leave it in
I.M. Hildingsson, A.-K. Sandin-Boj¨ o / Midwifery 27 (2011) 737–744
a sealed envelope. They also had the opportunity to take the questionnaires home and return them in a stamped addressed envelope. Two reminder letters were sent to non-responders after two and four weeks, respectively. Two months after birth, a new questionnaire was sent to the women’s home addresses with two similar reminders for non-responders.
Data collection This report is based on selected data from the questionnaires completed by the women. Background data (age, civil status, education, country of birth, smoking preference, and parity were used from the first questionnaire). The questionnaire completed two months after birth included one section regarding postnatal care received (model of care, length of stay, opinion on postnatal length) and one section regarding experiences of postnatal care (satisfaction with the medical aspects, the emotional aspects and an overall assessment of the postnatal care). To assess satisfaction with postnatal care, previously used questions from a national ¨ et al., 2006) were modified using a Swedish survey (Waldenstrom quality assessment model developed by Wilde et al. (1994), ‘Quality of Care from the Patient’s Perspective’ (QPP), which has been validated in several areas of health care. The way in which the quality of care was perceived by the individual was measured by requiring the individual to consider their experiences in relation to a statement. Each question was judged both for perceived reality (PR) of the care received and for subjective importance (SI) of that particular item. The women were asked to respond to 10 different questions about postnatal care in two ways. First they were asked to evaluate their experience (PR), and then they were asked to evaluate the importance of that aspect of care (SI). For example, ‘I received enough information about breast feeding’, was asked with response categories ranging from ‘do not agree at all’ (1) to ‘totally agree’ (4). The women were then asked how important this aspect of care was, with response categories ranging from ‘of little importance’ (1) to ‘of very great importance’ (4) (Wilde et al., 1994). On some items, women answered ‘not applicable’, and these items were excluded from the analyses. The questions were checked for face validity with 12 new mothers. Only minor wording was changed due to their comments. Reliability was assessed with the Cronbach alpha coefficient; the scale showed an internal consistency of 0.89 for PR and 0.88 for SI. An index was created by combining the answers of SI and PR. The index was based on a description provided by the creators of the QPP scale (Wilde et al., 2001). The idea behind the index is that different combinations of answers to questions on PR and SI should lead to different actions taken. ‘Balanced’ care occurs when the care given reflects the needs of the respondent, e.g. high or low scores on both SI and PR. ‘Deficient’ care contains aspects that are deemed important by the respondent, but the actual delivery of the care is perceived as less than good. Quality improvement measures in this sphere should be given high priority. ‘Excessive’ care contains aspects that are not deemed important by the respondent, but the actual delivery of care is perceived as far beyond their expectations (this is also described as ‘too much care’). The recommendations from the creators of the QPP instrument are that if 420% report deficient care for a specific issue, action should be taken. On the other hand, if the subjects are given more care than needed, described as ‘excessive’ or ‘too much’ care ( 420% report excess), this should be noted. Statistical analyses were conducted using the Statistical Package for Social Sciences version 17.0 (SPSS, Inc., Chicago, IL,
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USA). Differences in background data were calculated using a
w2 test. Thereafter, mean values and standard deviations were calculated for the different content issues, and comparisons were made between primiparas and multiparas using independent t-tests. A one-way between-group analysis of variance was conducted to study the relationship between the content of postnatal care and the different models of care (Pallant, 2007). A p-value o0.05 was interpreted as statistically significant. Finally, in order to explain which factors were most strongly related with women being ‘very satisfied’ with the medical and emotional aspects of postnatal care, multivariate logistic regression analyses were used (Rothman, 2002).
Table 1 Description of study sample. Primiparas n ¼ 550 n (%)
Multiparas n ¼ 690 n (%)
v2-test p-Value
Socio demographic background Age (years) o 25 25–35 435
132 (24.0) 380 (69.19) 38 (6.9)
43 (6.2) 510 (73.9) 137 (19.9)
o0.001
Civil status Married/cohabiting Not married/cohabiting
520 (96.4) 20 (3.6)
668 (96.8) 22 (3.2)
0.752
Education Elementary school High school College/university
29 (5.3) 240 (44.0) 274 (50.5)
33 (4.9) 296 (43.9) 345 (51.2)
0.926
20 (3.6) 16 (2.9)
45 (6.5) 40 (5.8)
0.029 0.019
Obstetric data Complicated pregnancy
139 (33.6)
150 (29.6)
0.200
Mode of birth Vaginal birth Instrumental vaginal Elective caesarean section Emergency caesarean section
266 68 23 62
413 16 41 42
Complications during birth
134 (33.3)
Postnatal care received Model of care Home directly from childbirth unit Traditional postnatal ward Hotel ward Co-care neonatal unit Mean length of stay (hours)
4 300 79 30 79.5
Born outside Sweden Smoking
(63.5) (16.2) (5.5) (14.8)
(1.0) (72.6) (19.1) (7.3) (60.02)
Women’s opinion about length of stay Too short 38 (9.3) Sufficient 325 (79.7) Too long 45 (11.0)
Satisfaction with postnatal care Very satisfied with medical aspects of care Very satisfied with emotional aspects of care Very satisfied with overall assessment of postnatal care
(80.7) (3.1) (8.0) (8.2)
o0.001
102 (20.3)
o0.001
33 343 105 19 55.07
(6.6) (68.6) (21.0) (3.8) (51.26)
o0.001 o0.001
61 (12.2) 394 (79.0) 44 (8.8)
0.237
192 (45.7)
242 (47.2)
0.692
135 (32.1)
168 (32.7)
0.888
184 (43.8)
218 (42.5)
0.691
740
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Findings Participants During 2007, 2512 routine ultrasound examinations were performed in the three hospitals. The following women were excluded from the study for various reasons: 129 did not master the Swedish language, 22 pregnancies had malformations, six women were not approached and eight women were moving from the area shortly after the ultrasound examination. This left a total of 2347 women who were eligible for the study. Of that total, 1506 women (64% of those eligible) consented to participate, and of this group, background data collected from 1240 women (53% of those eligible, 82% of those who consented) who returned the first questionnaire were used. Of the 1506 women who consented to participate, some were lost to follow-up for different reasons, such as: moved from the area (n ¼15), late miscarriage or stillbirth (n ¼10), or reluctance to return the first questionnaire (n¼279). The follow-up questionnaire two months after birth was completed by 936 women (75%). Of the 1240 women included in the study, 550 (44%) were primiparas and 690 (56%) were multiparas (Table 1). The majority of participants were aged 25–35 years, married/cohabiting, of Swedish origin and had a college or university degree. Multiparous women were older, more often born outside Sweden, and were more often smokers compared with primiparous women. There were no differences in civil status, education or the occurrence of complicated pregnancies, e.g. pre-eclampsia, diabetes or symphysiolysis. In all, 73% had a vaginal birth, 9% had an instrumental vaginal birth and 18% had caesarean section. Primiparas had more instrumental vaginal births and emergency caesarean sections as well as medical complications during birth. Only a few mothers (4%) went home directly from the delivery unit after birth. The majority stayed at a traditional postnatal ward, and approximately 20% stayed in family suites on the hotel ward. The mean length of stay was approximately three days for primiparas and just above two days
for multiparas. Fewer than 50% of the women reported being ‘very satisfied’ with the medical care as well as the overall assessment of postnatal care. Women were least satisfied with the emotional aspects of care, with less than one-third reporting being ‘very satisfied’. There was no difference related to parity in the levels of satisfaction (Table 1). Differences between subjective importance and perceived reality of the content of postnatal care For both primiparas and multiparas, there was a statistically significant difference between SI and PR for all studied variables, with SI greater than PR for all statements (data not shown). In Table 2, participants’ assessment of the content of postnatal care shows the mean ranks of women’s SI and the PR of postnatal care. Primiparas reported the highest SI scores for ‘The infant got the best possible check-ups/medical care’, followed by ‘I received good treatment’, and ‘I received enough information about the infant’s needs’. Least important was ‘I received enough information about intimate life’. Primiparas reported the highest PR scores for ‘The infant got the best possible check-ups/medical care,’ ‘I received good treatment’ and ‘I received enough support from the staff ’. The lowest rankings were received for ‘I received enough information about intimate life’ and ‘I received enough practical instructions on how to take care of the infant’. Multiparas’ SI scores were highest for ‘The infant got the best possible check-ups/medical care’, followed by staff- related variables such as ‘I received good treatment’ and ‘I received enough support from the staff ’. These items were also scored highest for PR. ‘I received enough information about intimate life’ had the lowest score for PR. When primiparas and multiparas were compared, the results showed statistically significant differences in relation to parity for all of the variables when SI was compared, with primiparas rating nine out of 10 of the variables higher than multiparas (Table 2). There were no major differences between primiparas and multiparas in the PR of their postnatal care, with the exception of ‘I
Table 2 Women’s assessment of their postnatal care. Statements about the postnatal care
Primiparas
Multiparas
Differences in parity and
Differences in parity and
SI Mean (SD)
PR Mean (SD)
SI Mean (SD)
PR Mean (SD)
SI p-Value
PR p-Value
Satisfaction with information I received enough information about physical changes I received enough information about emotional changes I received enough information about breast feeding
3.29 (0.71) 3.30 (0.69) 3.57 (0.63)
2.59 (1.00) 2.49 (1.00) 2.67 (1.04)
2.97 (0.88) 2.92 (0.90) 3.11 (0.90)
2.81 (1.00) 2.59 (1.03) 2.89 (0.98)
o0.001 o0.001 o0.001
o 0.001 0.153 o 0.001
I received enough information about intimate life I received enough information about the infant’s needs
2.93 (0.87) 3.72 (0.53)
2.39 (1.10) 2.72 (0.92)
3.16 (0.86) 3.28 (0.84)
2.37 (1.10) 2.81 (0.94)
o0.001 o0.001
0.632 0.166
I received enough practical instruction on how to take care of the infant
3.48 (0.75)
2.39 (1.06)
3.00 (1.02)
2.57 (1.09)
o 0.000
0.023
I received enough practical instruction about breast feeding
3.60 (0.62)
2.74 (1.11)
3.11 (0.95)
2.74 (1.11)
o0.001
0.912
The infant got the best possible check-ups/medical care
3.91 (0.29)
3.60 (0.71)
3.86 (0.37)
3.53 (0.78)
0.038
0.173
I received good treatment
3.76 (0.45)
3.34 (0.88)
3.70 (0.51)
3.43 (0.83)
0.047
0.088
I received enough support from the staff
3.66 (0.54)
3.07 (1.00)
3.53 (0.68)
3.20 (0.93)
o0.001
0.043
PR, perceived reality; SI, subjective importance.
0.014 0.001 22 (60.0) 0 23 (51.1) 0 96 (56.1) 18 (10.5) 18 (40.0) 78 (47.9) 14 (8.6) 22 (48.9) 57 (33.3) 71 (43.6) 407 (64.3) 56 (8.8) 358 (57.1) 62 (9.9) 170 (26.9) 207 (33.0) 18 (69.2) 13 (56.5) 3 (11.0) 4 (17.4)
5 (19.2) 6 (26.1)
0.021 25 (61.0) 1 (2.4) 15 (36.6) 58 (33.3) 113 (64.9) 3 (1.7) 482 (76.9) 12 (1.9) 133 (21.2) 19 (73.1) 6 (23.1)
1 (3.8)
22 (55.0) 4 (10.0) 0.002 14 (35.0) 60 (37.3) 14 (8.7) 87 (54.0) 249 (44.3) 70 (12.5) 243 (43.2) 12 (48.0) 5 (20.0)
8 (32.0)
21 (55.3) 43 (30.3) 11 (7.7) 88 (62.0) 52 (9.7) 205 (38.1) 281 (52.2) 6 (22.2) 13 (48.1) 8 (29.6)
I received enough practical instruction about how to take care of the infant I received enough practical instruction about breast feeding The infant got the best possible check-ups/medical care I received good treatment I received enough support from the staff
0.001 0.000 0.000 0.220 0.000 (7.0) (7.1) (4.7) (10.0) 3 3 2 3 0 (37.2) (31.0) (46.5) (48.3) (47.5) 16 13 20 13 19 (55.8) (61.9) (48.8) (46.7) (52.5) 24 26 21 14 21 (19.1) (14.0) (7.6) (21.3) (7.1) 33 24 13 32 12 (34.1) (35.5) (37.4) (32.0) (30.4) 59 61 64 48 51 (46,8) (50.6) (35.0) (46.7) (62.5) 104 (17.0) 81 69 (11.1) 87 87 (14.3) 94 98 (18.2) 70 36 (6.0) 105 (42.0) (44.4) (41.7) (42.5) (43.1) 256 263 254 228 246 (41.0) (44.0) (44.0) (39.3) (52.9)
Excess n (%) Balance n (%) Deficiency n (%) Excess n (%) Balance n (%) Deficiency n (%) Excess n (%) Balance n (%) Deficiency n (%)
250 261 268 211 317 14 (41.2) 11 (32.4) 14 (42.4) 4 (16.0) 4 (14.8) (35.3) (47.1) (39.4) (52.0) (63.0) 12 16 13 13 17 (23.5) (20.5) (18.2) (32.0) (22.2) 8 7 6 8 6
Went home directly from the childbirth unit (n ¼37)
physical changes emotional changes breast feeding intimate life the needs of the infant Satisfaction with information I received enough information about I received enough information about I received enough information about I received enough information about I received enough information about
The main findings of this study revealed great discrepancies between women’s SI and PR of postnatal care. There were also differences in the quality assessment between models of care. The most important variables for being ‘very satisfied’ with postnatal care were that the infant got the best possible check-ups/medical care and that the woman received enough support from staff. The discrepancy between women’s evaluation of their experiences of postnatal care and the importance of that aspect of care in this study is interesting, and shows that postnatal care could indeed be better for the questioned variables. Earlier studies have shown that if more than one dimension of care is requested ¨ (Rudman and Waldenstrom, 2007) or if both SI and PR are investigated (Sandin-Bojo¨ et al., in press), women are less satisfied than when asking just an overall question.
Statements about postnatal care
Discussion
Table 3 Quality of postnatal care from women’s perspectives in relation to model of care.
The most important factors for being ‘very satisfied’ with the postnatal care are shown in Table 4. Two variables were related to satisfaction with both the medical and the emotional aspects of postnatal care regardless of parity, namely ‘The infant got the best possible check-ups/medical care’ and ‘I received enough support from the staff ’. Viewing the postnatal stay as too short was related to dissatisfaction with the emotional aspects of care for both primi- and multiparas. Being ‘very satisfied’ with the medical aspects was also related to ‘I received good treatment’, ‘I received enough information about physical changes’ and ‘I received enough information about breast feeding’ in first-time mothers. Information regarding the statement ‘I received enough information about the infant’s needs’ was a strong explanatory factor for mothers with previous children who were also less satisfied with the medical aspects if they viewed the postnatal stay as too long. For satisfaction with the emotional aspects of care in primiparas ‘I received enough information about emotional changes’, ‘I received enough information about the infant’s needs’ and ‘I received good treatment’ were important. In multiparas, ‘I received enough practical instructions about how to take care of the infant’ reached statistical significance. The model of postnatal care was not a contributing factor in any of the studied outcomes.
Traditional postnatal ward (n ¼ 613)
Satisfaction with the medical and emotional aspects of postnatal care
Excess n (%)
Hotel ward (n ¼ 184)
The quality of postnatal care was examined using the created index in relation to the model of postnatal care. There were statistically significant differences for all the studied variables, with the exception of ‘I received enough information about intimate life’ when the models of care were compared (Table 3). Women who went home directly from the delivery unit reported the least balanced care, with deficient care reported for seven out of 10 variables. This was the only group that reported ‘excessive care’ and did so in six out of 10 variables. Women in the traditional postnatal wards, hotel ward and those who had cocare on neonatal wards reported deficient care in all studied variables, and no variable reached 20% in excesses.
Balance n (%)
Women’s assessment of the quality of postnatal care in relation to model of care
Deficiency n (%)
Co-care neonatal ward (n ¼49)
p-Value
received enough information about physical changes’ and ‘I received enough information about breast feeding’, where primiparas rated scores lower compared with multiparas (Table 2).
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13 (34.2) 4 (10.5) 0.047
I.M. Hildingsson, A.-K. Sandin-Boj¨ o / Midwifery 27 (2011) 737–744
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Table 4 Logistic regression model of factors associated with being ‘very satisfied’ with postnatal care. Primiparas OR (95% CI) Medical aspects of postnatal care The infant got the best possible check-ups/medical care I received enough support from the staff I received good treatment I received enough information about physical changes I received enough practical instruction about breast feeding I received enough information about the infant’s needs The hospital stay was too long
Emotional aspects of postnatal care The infant got the best possible check-ups/medical care I received enough support from the staff I received enough information about emotional changes I received good treatment I received enough information about the infant’s needs The hospital stay was too short I received enough practical instruction about how to take care of the infant
Women who went home directly from the delivery unit without staying in the postnatal ward or in the hotel ward reported the least balanced care and differed from women using other care options in terms of reporting ‘less care than needed’ (in seven out of 10 variables) and ‘more care than needed’ (in six out of 10 variables). However, the number of women in this group was small (n¼37). It is not known why women chose to go home directly. One reason could be that they felt that they had more support at home than, for example, in the hotel ward, or that they were not pleased with the care offered, or felt obliged to leave the hospital as soon as possible. The three hospitals under study had different approaches to new mothers. In the smaller hospitals, women could stay on the postnatal ward up to three days after a normal birth, whereas the only option in the large hospital was the hotel ward for this group of new mothers. It is possible that women viewed that option as too narrow, as there was no possibility to get help with the infant during the night, which is one factor identified in dissatisfaction with postnatal care (Hildingsson, 2007; Hildingsson and Thomas, 2007). The finding that the women who went home directly after birth got more care than needed (e.g. excessive care) could probably be explained by their previous experience as the majority of women using this model of care were multiparas with previous experience of a newborn infant and may not have needed more information. Another explanation could be that this group of women went home for other reasons. In the early stages ¨ and Lindmark (1987) pointed out of early discharge, Waldenstrom that women who choose early discharge had a less positive attitude to postnatal care in hospital and greater self- confidence concerning birth and parenthood. Women in the traditional postnatal wards, hotel ward and those who had co-care on neonatal wards reported deficient care in all studied variables and no variable reached 20% in excesses. The reasons for this can only be speculated. One explanation could be that the women’s expectations about postnatal care were too high. One can assume that new mothers have heard stories from their own mothers who were likely to receive a longer stay (five days after a normal birth in 1976), when the infants were taken care of by nannies in special baby units and where the mothers were told to rest and recover after birth. Another explanation could be that the women did not receive enough information about the time following birth during pregnancy; a factor that parents regarded afterwards as unsatisfactory (Kline
2.9 3.6 2.5 2.3 1.8
2.5 5.0 2.5 2.6 2.0 0.2
(1.6–5.4) (1.9–6.6) (1.3–4.5) (1.1–4.9) (1.0–3.2)
(1.1–5.6) (2.6–9.7) (1.25.4) (1.2–5.4) (1.0–3.7) (0.1–0.8)
p-Value
0.001 0.000 0.003 0.020 0.049
0.028 0.005 0.015 0.012 0.038 0.023
Multiparas OR (95% CI)
p-Value
4.38 (2.7–7.0) 5.3 (3.2–8.6)
0.000 0.000 0.000
3.6 (1.9–6.8) 0.2 (0.1–0.6)
0.000 0.001
2.4 (1.4–4.2) 8.0 (4.9–12.9)
0.002 0.000
0.3 (0.1–0.7) 3.7 (1.9–7.1)
0.005 0.000
et al., 1998; Bogren Jungmarker et al., in press). It has, however, been assumed that caregivers perceive pregnant women as less perceptive of issues beyond labour and birth in the antenatal period (Kline et al., 1998). A third explanation for the discrepancies could be related to the length of stay with the intense information given, which earlier studies have also shown (Brown et al., 2002; Hildingsson, 2007). Although the postnatal care was organised differently, the mean time for postnatal care was less than three days. Nevertheless, short postnatal stay after childbirth was implemented for financial reasons, not for the new parents or for security reasons. The result signals that parents do not have the time to adjust to the parental role during the hospital stay. Two variables were related to satisfaction with both the medical and the emotional aspects of postnatal care regardless of parity, namely that the infant got the best possible check-ups/ medical care and the women got enough support from staff. Check-ups/medical care of the infant were important factors in being ‘very satisfied’ with the postnatal care received, which is in accordance with previous studies (Hildingsson et al., 2001; Hildingsson, 2007; Sandin-Bojo¨ et al., 2008). The health and well-being of the infant is one of the most important variables according to women’s views (Geissbuehler and Eberhard, 2002), and worries about the infant’s health have been mirrored in studies reporting that new parents seek care for the infant to a high degree during the first weeks after discharge from hospital after childbirth (Ellberg et al., 2005). However, it is unclear what women actually view as sufficient check-ups/medical care. This should be a subject for further qualitative research. It might be that the profession emphasises check-ups/medical care, and thereby gives the impression that this is more important than anything else. Support from staff was the other factor important for both the medical and emotional aspects of care. Support from staff has previously been reported by parents as a major issue in surveys of postnatal care (Brown et al., 2005; Lindberg et al., 2008; ¨ et al., 2006; Yelland et al., 2007). Previous studies Waldenstrom have shown that with limited personal resources due to lack of midwives or financial restrictions, staff working on postnatal wards perceive the strain and stress of not being able to give the best care (Yelland et al., 2007). It has also been reported that midwives simply do not have the time to give adequate support (Rayner et al., 2008). Early postnatal care in hospital with short length of stay and reduced possibilities for staff to provide
I.M. Hildingsson, A.-K. Sandin-Boj¨ o / Midwifery 27 (2011) 737–744
support could perhaps diminish the staffs’ interest in new mothers. This could make the mothers feel less welcome. It is obvious that the postnatal care has to be changed, although it is still unclear how and what should be changed. This study has several limitations. First, as this was a regional study, the findings can only be generalised to postnatal care in similar areas. Another limitation is that only 53% of those eligible chose to participate in the survey. One explanation could be that people in this area are not approached for research projects in the same way as in more urban areas. Another explanation could be that the women lacked time to complete the questionnaires or that the timing of recruitment (antenatally) for a study of this type (postnatal care) may have had an impact on participation, which was mirrored in the fairly high drop-out rates. The study was also compromised by the exclusion of non-Swedish-speaking women who perhaps have other needs due to cultural and/or health-related issues. It is known from earlier studies that foreign-born women are less likely to participate in parent education classes (Fabian et al., 2004), but are more exposed to ill health during pregnancy and childbirth (Bollini et al., 2009). Another limitation is that the women’s responses provide their subjective views on the issue; there is no evidence of the actual information or care given. In addition, the timing for answering the questionnaire may have influenced the results. The strength of this study lies in its relatively large sample of new mothers. The women included in the study, although all living in one region in Sweden, lived in large cities as well as rural areas. The use of independently completed questionnaires prevents interviewrelated bias. On the other hand, closed-ended questions imply limited options that can hold back responders from answering in greater detail. It is important to distinguish between satisfaction with the actual care given and the importance of various components of care for the individual; the analysis of the index measure combined with SI and PR provide indications of areas where improvement would be valuable.
Conclusion This study adds to the growing literature on postnatal care and thus the lack of satisfaction. Similar factors have previously been reported, such as check-ups/medical care of the infant, length of postnatal stay and support from staff. However, to the authors’ knowledge, no study has incorporated the subjective importance and the perceived reality of the different issues of postnatal care. Asking women/patients about both perspectives adds information when quality aspects are measured and could be recommended for a broader understanding. Further studies are needed to assess the best model of postnatal care that gives the best opportunities to provide satisfactory care for women and their families.
Acknowledgements We thank the women who participated in the study and the midwives who helped in the recruitment process. The study was funded by the Swedish Research Council, the County Council of ¨ Vasternorrland, Mid Sweden University and Karlstad University. References Bluff, R., Holloway, I., 1994. They know best: women’s perception of midwifery care during labour and childbirth. Midwifery 101, 157–164. Bogren Jungmarker, E., Lindgren H., Hildingsson, I., . in press, Playing the second violin is ok—Swedish fathers’ experiences of antenatal care. Journal of Midwifery and Women’s Health.
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Bollini, P., Pampallona, S., Wanner, P., Kupelnick, B., 2009. Pregnancy outcome of migrant women and integration policy: systematic review of the international literature. Social Sciences and Medicine 68, 452–461. Bramadat, I.J., Driedger, M., 1993. Satisfaction with childbirth: theories and methods of measurement. Birth 20, 22–29. Brown, S., Lumley, J., 1997. The 1993 survey of recent mothers: issues in survey design, analysis and influencing policy. International Journal of Quality in Health Care 9, 265–275. Brown, S., Small, R., Argus, B., Davis, P.G., Krastev, A., 2002. Early postnatal discharge from hospital for healthy mothers and term infants. Cochrane Database of Systematic Reviews, CD002958. Brown, S., Bruinsma, F., Darcy, M.-A., Small, R., Lumley, J., 2004. Early discharge: no evidence of adverse outcomes in three consecutive population-based Australian surveys of recent mothers, conducted in 1989, 1994 and 2000. Paediatric and Perinatal Epidemiology 18, 202–213. Brown, S.J., Davey, M.A., Bruinsma, F.J., 2005. Women’s views and experiences of postnatal hospital care in the Victorian Survey of Recent Mothers 2000. Midwifery 21, 109–126. Carr-Hill, R.A., 1992. The measurement of patient satisfaction. Journal of Public Health Medicine 14, 236–249. ¨ Ellberg, L., Lundman, B., Persson, M.E., Hogberg, U., 2005. Comparison of health care utilization of postnatal programs in Sweden. Journal of Obstetric, Gynecologic, and Neonatal Nursing 34, 55–62. ¨ Ellberg, L., Hogberg, U., Lundman, B., Lindholm, L., 2006. Satisfying parents’ preferences with regard to various models of postnatal care is costminimizing. Acta Obstetricia et Gynecologica Scandinavica 85, 175–181. ¨ Ellberg, L., Hogberg, U., Lindh V., 2008. We feel like one, they see us like two: new parents’ discontent with postnatal care. Midwifery December 10 (Epub ahead of print). ˚ ¨ Fabian, H., Radestad, I., Waldenstrom, U., 2004. Characteristics of Swedish women who do not attend childbirth and parenthood education classes during pregnancy. Midwifery 20, 226–236. Forster, D., McLachlan, H., Yelland, J., Rayner, J., Lumley, J., 2005. PinC. A Review of in-Hospital Postnatal Care in Victoria. La Trobe University, Melbourne. Forster, D.A., McLachlan, H.L., Yelland, J., Rayner, J., Lumley, J., Davey, M.A., 2006. Staffing in postnatal units: is it adequate for the provision of quality care? Staff perspectives from a state-wide review of postnatal care in Victoria, Australia. BMC Health Service Research 4, 83. Geissbuehler, V., Eberhard, J., 2002. Fear of childbirth during pregnancy: a study of more than 8000 pregnant women. Journal of Psychosomatic Obstetrics and Gynaecology 23, 229–235. Hagenfeldt, K., Alton, V., Axelsson, O., 1998. Routine Ultrasound Examination in Pregnancy. SBU-Report No. 139. The Swedish Council on Technology Assessment in Health Care, Stockholm (in Swedish). ¨ ˚ Hildingsson, I., Waldenstrom, U., Radestad, I., 2001. Women’s expectations on prenatal care as assessed in early pregnancy: number of visits, continuity of caregiver and general content. Acta Obstetricia et Gynecologica Scandinavica 81, 118–125. Hildingsson, I., 2007. New parents’ experiences of postnatal care in Sweden. Women and Birth 20, 105–113. Hildingsson, I., Thomas, J., 2007. Processes, problems and solutions: maternity care from the women’s perspective. Journal of Midwifery and Women’s Health 52, 126–133. ¨ Hildingsson, I., Engstrom-Olofsson, R., Thomas, J., Nystedt, A., 2009. Still behind the glass wall? Fathers’ experiences of postnatal care. Journal of Obstetric, Gynecologic and Neonatal Nursing 38, 280–289. Hundley, V., Ryan, M., 2004. Are women’s expectations and preferences for intrapartum care affected by the model of care on offer? British Journal of Obstetrics and Gynaecology 111, 550–560. Kline, C.R., Martin, D.P., Deyo, R.A., 1998. Health consequences of pregnancy and childbirth as perceived by women and clinicians. Obstetrics and Gynaecology 92, 842–848. ¨ hrling, K., Christensson, C., 2008. Expectations of post-partum care Lindberg, I., O among pregnant women living in the north of Sweden. International Journal of Circumpolar Health 67, 472–483. McLachlan, H., Forster, D., Yelland, J., Rayner, J., Lumley, J., 2007. Is the organization and structure of hospital postnatal care a barrier to quality care? Findings from a state-wide review in Victoria, Australia. Midwifery 24, 358–370. Pallant., J., 2007. SPSS Survival Manual. 3rd edn. Allen & Unwin, Sydney. Rothman, K., 2002. Epidemiology—an Introduction. Oxford University Press, New York. Rayner, J.A., Forster, D., McLachlan, H., Yelland, J., Davey, M.A., 2008. A state-wide review of hospital postnatal care in Victoria, Australia: the views and experiences of midwives. Midwifery 24, 310–320. ¨ Rudman, A., Waldenstrom, U., 2007. Critical views on postpartum care expressed by new mothers. BMC Health Service Research 5, 178. ¨ A.-K., Wilde-Larsson, B., Hall-Lord, M.-L., 2008. Women’s perception Sandin-Bojo, of intrapartal care in relation to WHO recommendations. Journal of Clinical Nursing 17, 2993–3003. ¨ A., Wilde-Larsson, B., Berg, M. Kvist, L.J. What is, could be better: Sandin-Bojo, Swedish women’s perceptions of their intrapartal care during planned vaginal birth. International Journal of Health Care Quality Assurance (in press). Sitzia, J., Wood, N., 1997. Patient satisfaction: a review of issues and concepts. Social Science and Medicine 45, 1829–1843. Swedish National Board of Health and Welfare, 2008. Pregnancies, Deliveries and Newborn Infants. The Swedish Medical Birth Register 1973 2006. Official Statistics of Sweden. Socialstyrelsen, Stockholm.
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Spurgeon, P., Hicks, C., Barnell, F., 2001. Antenatal, delivery and postnatal comparisons of maternal satisfaction with two pilot changing childbirth schemes compared with traditional model of care. Midwifery 17, 123–132. van Teijlingen, E.R., Hundley, V., Rennie, A.M., Graham, W., Fitzmaurice, A., 2003. Maternity satisfaction studies and their limitations: ‘what is, must still be best’. Birth 30, 75–82. ¨ Waldenstrom, U., Lindmark, G., 1987. Early and late discharge after hospital birth. A comparative study of parental background characteristics. Scandinavian Journal of Social Medicine 15, 159–167. ¨ Waldenstrom, U., Brown, S., McLachlan, H., Forster, D., Brennecke, S., 2000. Does team midwifery increase satisfaction with antenatal, intrapartum and postpartum care? A randomized controlled trial. Birth 27, 168–173.
¨ Waldenstrom, U., Rudman, A., Hildingsson, I., 2006. Intrapartum and postpartum care in Sweden. Women’s opinions and risk factors for not being satisfied. Acta Obstetricia et Gynaecologica Scandinavica 85, 551–560. Wilde, B., Larsson, G., Larsson, M., Starrin, B., 1994. Quality of care. Development of a patient-centred questionnaire based on a grounded theory model. Scandinavian Journal of Caring Sciences 8, 39–48. Wilde, B., Larsson, G., Larsson, M., Starrin, B., 2001. Quality from the Patient’s ˚ ¨ Perspective. [KUPP-boken—Kvalitet ur Patientens Perspektiv]. Vardf orbundet, Stockholm. Yelland, J., Krastev, A., Brown, S., 2007. Enhancing early postnatal care: findings from a major reform of maternity care in three Australian hospitals. Midwifery doi:10.1016/j.midw.2007.01.0040.
Contents lists available at ScienceDirect
Midwifery journal homepage: www.elsevier.com/midw
‘What is could indeed be better’—Swedish women’s perceptions of early postnatal care ¨ Ingegerd M. Hildingsson, RN, RM, PhD (Associate Professor)a,n, Ann-Kristin Sandin-Bojo, RN, RM, PhD (Senior Lecturer)b a b
Department of Health Sciences, Mid Sweden University, SE-851 70 Sundsvall, Sweden Division for Health and Caring Sciences, Karlstad University, SE 651 88 Karlstad, Sweden
a r t i c l e in fo
abstract
Article history: Received 15 January 2010 Received in revised form 7 April 2010 Accepted 11 April 2010
Background: studies have shown that women are more likely to be satisfied with intrapartum rather than postpartum care. The structure and organisation of care seems to be a barrier to good-quality postpartum treatment Objective: to explore the perceived reality and the subjective importance of early postnatal care provided in hospital, and to study women’s satisfaction with different models of early postnatal care and the factors that are most strongly associated with being ‘very satisfied’ with the postnatal care received. Method: a regional survey was conducted with 1240 women recruited in mid-pregnancy and followed-up two months after childbirth. Results: a statistically significant difference existed between the subjective importance and the perceived reality for all studied variables, with a greater subjective importance than perceived reality for all statements. The length of postnatal stay and the content of care were related to satisfaction, while the model of postnatal care was not. The most important variables for being ‘very satisfied’ with postnatal care were that the infant received the best possible check-ups/medical care, and that the woman received sufficient support from staff. Conclusion: further studies are needed to assess the best model of postnatal care that gives the best opportunities to provide satisfactory care for women and their families. & 2010 Elsevier Ltd. All rights reserved.
Keywords: Postnatal care Quality assessment
Introduction Contemporary postnatal care in most Western countries is characterised by a short length of stay (Brown et al., 2002; Hildingsson and Thomas, 2007), information intense content (McLachlan et al., 2007) and high parental responsibility in the care of the newborn infant (Hildingsson, 2007; Rudman and ¨ Waldenstrom, 2007; Hildingsson et al., 2009). Barriers to satisfaction of postpartum care have been linked to the structure and organisation of care. In a state-wide review of postnatal care in Australian hospitals, caregivers identified hindrances such as lack of continuity of care and the length of postnatal stay (Forster et al., 2005; McLachlan et al., 2007). Caregivers reported that there was limited time available to spend with women and further indicated problems with staffing (Forster et al., 2006; Rayner et al., 2008). Given the problems identified with postnatal care, different authors have suggested that individualised care, continuity of care and a flexible length of
n
Corresponding author. E-mail address: [email protected] (I.M. Hildingsson).
0266-6138/$ - see front matter & 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.midw.2010.04.007
stay could enhance satisfaction with postnatal care (Hildingsson, 2007; Hildingsson and Thomas, 2007; Lindberg et al., 2008; Rayner et al., 2008). During the last 10–15 years, new models of early postnatal care such as early discharge and family suites have been introduced as alternatives to traditional postnatal care. Team ¨ et al., 2000; Spurgeon et al., 2001) and midwifery (Waldenstrom family suites (Ellberg et al., 2006) increased the women’s satisfaction with their postnatal care. In addition to increased ¨ et al., 2006), family satisfaction (Ellberg et al., 2006; Waldenstrom suites/hotel wards seem to be a safe alternative in terms of re-admission (Ellberg et al., 2005). An Australian survey showed no association between early discharge, length of breast feeding and maternal depression (Brown et al., 2004). The content of early postnatal care has shifted throughout the years. Medical care and physical examinations of the woman after childbirth have, in some countries, diminished in favour of attention to the newborn (Hildingsson, 2007), but are still conducted in postnatal wards in other countries (McLachlan et al., 2007). Medical check-ups of the infant are one of the most valued and important care activities during pregnancy (Hildingsson et al., 2001), labour and birth (Sandin-Bojo¨ et al.,
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2008; Sandin-Bojo¨ et al., in press) and after childbirth (Hildingsson, 2007). Most studies on satisfaction with care during birth or after birth have identified areas that could be improved, such as ¨ father’s ability to stay overnight (Waldenstrom et al., 2006; Hildingsson, 2007; Ellberg et al., 2008; Hildingsson et al., 2009) ¨ and support from staff (Brown et al., 2005; Waldenstrom et al., 2006; Hildingsson, 2007; Ellberg et al., 2008; Hildingsson et al., 2009). When measuring women’s satisfaction with care, there are a number of methodological considerations. For example, the time point of investigation where it has been shown that satisfaction should not be measured too close to the birth but close enough for accurate recall (Bramadat and Driedger, 1993). Another issue is the dichotomisation of variables. Carr-Hill (1992) and Brown and Lumley (1997) suggested that all levels but being ‘very satisfied’ should be considered as sub optimal care. There is also a problem, as several researchers have previously indicated (Bluff and Holloway, 1994; van Teijlingen et al., 2003; Hundley and Ryan, 2004), that when questioned about quality and satisfaction with care during and after birth, there is a tendency for women to prefer the care they are familiar with, i.e. ‘what is, is best’. However, a recent study of intrapartal care measuring both the actually received care (perceived reality) and the subjective importance that women ascribed to the care showed that ‘what is, could be better’ (Sandin-Bojo¨ et al., in press). Patient satisfaction surveys are often the means utilised to evaluate experiences, e.g. the perceived reality of given care, but less often the subjective importance of the care received. A literature review by Sitzia and Wood (1997) identified the following different purposes for satisfaction measurements: to describe health-care services from the patient’s perspective; to assess the ‘process’ of care, identify problem areas and possible solutions; and to evaluate care. The objective of this study was to explore the perceived reality and the subjective importance of early postnatal care provided in hospital, and to study women’s satisfaction with different models of early postnatal care and the factors that are most strongly associated with being ‘very satisfied’ with postnatal care
Method This cross-sectional population-based study is one part of a regional prospective longitudinal survey of parents recruited in mid-pregnancy and followed-up in late pregnancy, two months and one year after childbirth. For the purpose of this specific paper, women who completed the third questionnaire two months after birth are included. The context of care in Sweden Midwives are the primary caregivers for women during prenatal care, birth and the early postnatal period in hospitals. Women with complications are treated by midwives in collaboration with their medical colleagues. Midwives perform all births with the exception of instrumental vaginal births and caesarean sections. Almost all care in Sweden is financed by the public health sector through taxes. Swedish midwives usually work in either community based prenatal care health clinics or in hospitals. In some cases, they may rotate between the labour ward and the postnatal ward. The average postnatal stay in hospital is two days (Swedish National Board of Health and Welfare, 2008). In some areas, midwives make home visits after discharge. Postnatal wards are usually staffed by midwives and enrolled nurses.
Models of postnatal care At the time of the investigation, there were four models of postnatal care available in the region: traditional postnatal ward, early discharge (from six hours after birth), co-care at the neonatal intensive care unit (NICU) and family suites on a patient hotel ward. Traditional ward and early discharge were available at all hospitals, but the hospitals had different approaches to postnatal care. In the largest hospital (with 1600 births/year), healthy mothers were not allowed to stay in the postnatal ward, but were recommended to either use the early discharge option or to have their postnatal stay in the hotel ward. In the smaller hospitals, all women had their early postnatal care in traditional postnatal wards or used early discharge. All hospitals have an NICU where parents could sometimes have co-care of the newborn, which meant that parents would be accommodated with their newborns. If all co-care rooms were occupied, women stayed in the postnatal ward or the hotel ward at night and made visits to the NICU at any time. Midwives from the postnatal ward also made visits to the NICU once or twice a day to care for the mother. In the NICU, partners were allowed to stay overnight in certain family rooms for co-care. Family suites in the hotel ward were introduced in the largest hospital two years prior to the investigation. The hotel ward is located in the hospital. Women with uncomplicated births and their partners can use the hotel option for postnatal care. From an administrative standpoint, the mother and the infant have been discharged when staying in the hotel ward. The hotel ward is staffed with a midwife during the day, but if problems occur during the night, parents call the traditional postnatal ward for help. Every morning, the midwife on duty at the hotel ward makes a telephone call to the parents to see if they need or want a visit. Otherwise, the parents are left alone to care for and bond with their infant. The midwives on the hotel ward also arrange revisits to the paediatrician for all parents and infants who took advantage of early discharge. In addition, they sometimes make home visits. The main reason for introducing this model of care was financial. The parents living in the region were free to choose a hospital. All women were informed about the different models of postnatal care by their antenatal midwife, and women’s preferences for postnatal care were usually written in the electronic records used during pregnancy, birth and postnatally.
Recruitment In 2007, women who were listed for a routine ultrasound at three hospitals in a county in the middle-north part of Sweden were invited to participate in a longitudinal study. There are seven municipalities in the county and three hospitals, of which one is a tertiary hospital with 1600 births annually; the other two are small community hospitals with 500 and 350 births, respectively. The ultrasound examination appointment was considered to be the best option to reach as many prospective parents as possible, due to the high attendance rate. Ultrasound examinations are routinely performed during weeks 17 19 in the pregnancy and are attended by the majority of women (Hagenfeldt et al., 1998). Occasionally, women chose not to have an ultrasound examination. Letters of invitation were sent two weeks prior to the screening appointment. Only Swedish-speaking women with a normal ultrasound examination were approached. After the ultrasound examination, the midwife in charge of the examination asked the women if they were willing to participate in the study. The women signed a consent form and were given the first questionnaire at the ultrasound ward, where they were asked to complete the form and leave it in
I.M. Hildingsson, A.-K. Sandin-Boj¨ o / Midwifery 27 (2011) 737–744
a sealed envelope. They also had the opportunity to take the questionnaires home and return them in a stamped addressed envelope. Two reminder letters were sent to non-responders after two and four weeks, respectively. Two months after birth, a new questionnaire was sent to the women’s home addresses with two similar reminders for non-responders.
Data collection This report is based on selected data from the questionnaires completed by the women. Background data (age, civil status, education, country of birth, smoking preference, and parity were used from the first questionnaire). The questionnaire completed two months after birth included one section regarding postnatal care received (model of care, length of stay, opinion on postnatal length) and one section regarding experiences of postnatal care (satisfaction with the medical aspects, the emotional aspects and an overall assessment of the postnatal care). To assess satisfaction with postnatal care, previously used questions from a national ¨ et al., 2006) were modified using a Swedish survey (Waldenstrom quality assessment model developed by Wilde et al. (1994), ‘Quality of Care from the Patient’s Perspective’ (QPP), which has been validated in several areas of health care. The way in which the quality of care was perceived by the individual was measured by requiring the individual to consider their experiences in relation to a statement. Each question was judged both for perceived reality (PR) of the care received and for subjective importance (SI) of that particular item. The women were asked to respond to 10 different questions about postnatal care in two ways. First they were asked to evaluate their experience (PR), and then they were asked to evaluate the importance of that aspect of care (SI). For example, ‘I received enough information about breast feeding’, was asked with response categories ranging from ‘do not agree at all’ (1) to ‘totally agree’ (4). The women were then asked how important this aspect of care was, with response categories ranging from ‘of little importance’ (1) to ‘of very great importance’ (4) (Wilde et al., 1994). On some items, women answered ‘not applicable’, and these items were excluded from the analyses. The questions were checked for face validity with 12 new mothers. Only minor wording was changed due to their comments. Reliability was assessed with the Cronbach alpha coefficient; the scale showed an internal consistency of 0.89 for PR and 0.88 for SI. An index was created by combining the answers of SI and PR. The index was based on a description provided by the creators of the QPP scale (Wilde et al., 2001). The idea behind the index is that different combinations of answers to questions on PR and SI should lead to different actions taken. ‘Balanced’ care occurs when the care given reflects the needs of the respondent, e.g. high or low scores on both SI and PR. ‘Deficient’ care contains aspects that are deemed important by the respondent, but the actual delivery of the care is perceived as less than good. Quality improvement measures in this sphere should be given high priority. ‘Excessive’ care contains aspects that are not deemed important by the respondent, but the actual delivery of care is perceived as far beyond their expectations (this is also described as ‘too much care’). The recommendations from the creators of the QPP instrument are that if 420% report deficient care for a specific issue, action should be taken. On the other hand, if the subjects are given more care than needed, described as ‘excessive’ or ‘too much’ care ( 420% report excess), this should be noted. Statistical analyses were conducted using the Statistical Package for Social Sciences version 17.0 (SPSS, Inc., Chicago, IL,
739
USA). Differences in background data were calculated using a
w2 test. Thereafter, mean values and standard deviations were calculated for the different content issues, and comparisons were made between primiparas and multiparas using independent t-tests. A one-way between-group analysis of variance was conducted to study the relationship between the content of postnatal care and the different models of care (Pallant, 2007). A p-value o0.05 was interpreted as statistically significant. Finally, in order to explain which factors were most strongly related with women being ‘very satisfied’ with the medical and emotional aspects of postnatal care, multivariate logistic regression analyses were used (Rothman, 2002).
Table 1 Description of study sample. Primiparas n ¼ 550 n (%)
Multiparas n ¼ 690 n (%)
v2-test p-Value
Socio demographic background Age (years) o 25 25–35 435
132 (24.0) 380 (69.19) 38 (6.9)
43 (6.2) 510 (73.9) 137 (19.9)
o0.001
Civil status Married/cohabiting Not married/cohabiting
520 (96.4) 20 (3.6)
668 (96.8) 22 (3.2)
0.752
Education Elementary school High school College/university
29 (5.3) 240 (44.0) 274 (50.5)
33 (4.9) 296 (43.9) 345 (51.2)
0.926
20 (3.6) 16 (2.9)
45 (6.5) 40 (5.8)
0.029 0.019
Obstetric data Complicated pregnancy
139 (33.6)
150 (29.6)
0.200
Mode of birth Vaginal birth Instrumental vaginal Elective caesarean section Emergency caesarean section
266 68 23 62
413 16 41 42
Complications during birth
134 (33.3)
Postnatal care received Model of care Home directly from childbirth unit Traditional postnatal ward Hotel ward Co-care neonatal unit Mean length of stay (hours)
4 300 79 30 79.5
Born outside Sweden Smoking
(63.5) (16.2) (5.5) (14.8)
(1.0) (72.6) (19.1) (7.3) (60.02)
Women’s opinion about length of stay Too short 38 (9.3) Sufficient 325 (79.7) Too long 45 (11.0)
Satisfaction with postnatal care Very satisfied with medical aspects of care Very satisfied with emotional aspects of care Very satisfied with overall assessment of postnatal care
(80.7) (3.1) (8.0) (8.2)
o0.001
102 (20.3)
o0.001
33 343 105 19 55.07
(6.6) (68.6) (21.0) (3.8) (51.26)
o0.001 o0.001
61 (12.2) 394 (79.0) 44 (8.8)
0.237
192 (45.7)
242 (47.2)
0.692
135 (32.1)
168 (32.7)
0.888
184 (43.8)
218 (42.5)
0.691
740
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Findings Participants During 2007, 2512 routine ultrasound examinations were performed in the three hospitals. The following women were excluded from the study for various reasons: 129 did not master the Swedish language, 22 pregnancies had malformations, six women were not approached and eight women were moving from the area shortly after the ultrasound examination. This left a total of 2347 women who were eligible for the study. Of that total, 1506 women (64% of those eligible) consented to participate, and of this group, background data collected from 1240 women (53% of those eligible, 82% of those who consented) who returned the first questionnaire were used. Of the 1506 women who consented to participate, some were lost to follow-up for different reasons, such as: moved from the area (n ¼15), late miscarriage or stillbirth (n ¼10), or reluctance to return the first questionnaire (n¼279). The follow-up questionnaire two months after birth was completed by 936 women (75%). Of the 1240 women included in the study, 550 (44%) were primiparas and 690 (56%) were multiparas (Table 1). The majority of participants were aged 25–35 years, married/cohabiting, of Swedish origin and had a college or university degree. Multiparous women were older, more often born outside Sweden, and were more often smokers compared with primiparous women. There were no differences in civil status, education or the occurrence of complicated pregnancies, e.g. pre-eclampsia, diabetes or symphysiolysis. In all, 73% had a vaginal birth, 9% had an instrumental vaginal birth and 18% had caesarean section. Primiparas had more instrumental vaginal births and emergency caesarean sections as well as medical complications during birth. Only a few mothers (4%) went home directly from the delivery unit after birth. The majority stayed at a traditional postnatal ward, and approximately 20% stayed in family suites on the hotel ward. The mean length of stay was approximately three days for primiparas and just above two days
for multiparas. Fewer than 50% of the women reported being ‘very satisfied’ with the medical care as well as the overall assessment of postnatal care. Women were least satisfied with the emotional aspects of care, with less than one-third reporting being ‘very satisfied’. There was no difference related to parity in the levels of satisfaction (Table 1). Differences between subjective importance and perceived reality of the content of postnatal care For both primiparas and multiparas, there was a statistically significant difference between SI and PR for all studied variables, with SI greater than PR for all statements (data not shown). In Table 2, participants’ assessment of the content of postnatal care shows the mean ranks of women’s SI and the PR of postnatal care. Primiparas reported the highest SI scores for ‘The infant got the best possible check-ups/medical care’, followed by ‘I received good treatment’, and ‘I received enough information about the infant’s needs’. Least important was ‘I received enough information about intimate life’. Primiparas reported the highest PR scores for ‘The infant got the best possible check-ups/medical care,’ ‘I received good treatment’ and ‘I received enough support from the staff ’. The lowest rankings were received for ‘I received enough information about intimate life’ and ‘I received enough practical instructions on how to take care of the infant’. Multiparas’ SI scores were highest for ‘The infant got the best possible check-ups/medical care’, followed by staff- related variables such as ‘I received good treatment’ and ‘I received enough support from the staff ’. These items were also scored highest for PR. ‘I received enough information about intimate life’ had the lowest score for PR. When primiparas and multiparas were compared, the results showed statistically significant differences in relation to parity for all of the variables when SI was compared, with primiparas rating nine out of 10 of the variables higher than multiparas (Table 2). There were no major differences between primiparas and multiparas in the PR of their postnatal care, with the exception of ‘I
Table 2 Women’s assessment of their postnatal care. Statements about the postnatal care
Primiparas
Multiparas
Differences in parity and
Differences in parity and
SI Mean (SD)
PR Mean (SD)
SI Mean (SD)
PR Mean (SD)
SI p-Value
PR p-Value
Satisfaction with information I received enough information about physical changes I received enough information about emotional changes I received enough information about breast feeding
3.29 (0.71) 3.30 (0.69) 3.57 (0.63)
2.59 (1.00) 2.49 (1.00) 2.67 (1.04)
2.97 (0.88) 2.92 (0.90) 3.11 (0.90)
2.81 (1.00) 2.59 (1.03) 2.89 (0.98)
o0.001 o0.001 o0.001
o 0.001 0.153 o 0.001
I received enough information about intimate life I received enough information about the infant’s needs
2.93 (0.87) 3.72 (0.53)
2.39 (1.10) 2.72 (0.92)
3.16 (0.86) 3.28 (0.84)
2.37 (1.10) 2.81 (0.94)
o0.001 o0.001
0.632 0.166
I received enough practical instruction on how to take care of the infant
3.48 (0.75)
2.39 (1.06)
3.00 (1.02)
2.57 (1.09)
o 0.000
0.023
I received enough practical instruction about breast feeding
3.60 (0.62)
2.74 (1.11)
3.11 (0.95)
2.74 (1.11)
o0.001
0.912
The infant got the best possible check-ups/medical care
3.91 (0.29)
3.60 (0.71)
3.86 (0.37)
3.53 (0.78)
0.038
0.173
I received good treatment
3.76 (0.45)
3.34 (0.88)
3.70 (0.51)
3.43 (0.83)
0.047
0.088
I received enough support from the staff
3.66 (0.54)
3.07 (1.00)
3.53 (0.68)
3.20 (0.93)
o0.001
0.043
PR, perceived reality; SI, subjective importance.
0.014 0.001 22 (60.0) 0 23 (51.1) 0 96 (56.1) 18 (10.5) 18 (40.0) 78 (47.9) 14 (8.6) 22 (48.9) 57 (33.3) 71 (43.6) 407 (64.3) 56 (8.8) 358 (57.1) 62 (9.9) 170 (26.9) 207 (33.0) 18 (69.2) 13 (56.5) 3 (11.0) 4 (17.4)
5 (19.2) 6 (26.1)
0.021 25 (61.0) 1 (2.4) 15 (36.6) 58 (33.3) 113 (64.9) 3 (1.7) 482 (76.9) 12 (1.9) 133 (21.2) 19 (73.1) 6 (23.1)
1 (3.8)
22 (55.0) 4 (10.0) 0.002 14 (35.0) 60 (37.3) 14 (8.7) 87 (54.0) 249 (44.3) 70 (12.5) 243 (43.2) 12 (48.0) 5 (20.0)
8 (32.0)
21 (55.3) 43 (30.3) 11 (7.7) 88 (62.0) 52 (9.7) 205 (38.1) 281 (52.2) 6 (22.2) 13 (48.1) 8 (29.6)
I received enough practical instruction about how to take care of the infant I received enough practical instruction about breast feeding The infant got the best possible check-ups/medical care I received good treatment I received enough support from the staff
0.001 0.000 0.000 0.220 0.000 (7.0) (7.1) (4.7) (10.0) 3 3 2 3 0 (37.2) (31.0) (46.5) (48.3) (47.5) 16 13 20 13 19 (55.8) (61.9) (48.8) (46.7) (52.5) 24 26 21 14 21 (19.1) (14.0) (7.6) (21.3) (7.1) 33 24 13 32 12 (34.1) (35.5) (37.4) (32.0) (30.4) 59 61 64 48 51 (46,8) (50.6) (35.0) (46.7) (62.5) 104 (17.0) 81 69 (11.1) 87 87 (14.3) 94 98 (18.2) 70 36 (6.0) 105 (42.0) (44.4) (41.7) (42.5) (43.1) 256 263 254 228 246 (41.0) (44.0) (44.0) (39.3) (52.9)
Excess n (%) Balance n (%) Deficiency n (%) Excess n (%) Balance n (%) Deficiency n (%) Excess n (%) Balance n (%) Deficiency n (%)
250 261 268 211 317 14 (41.2) 11 (32.4) 14 (42.4) 4 (16.0) 4 (14.8) (35.3) (47.1) (39.4) (52.0) (63.0) 12 16 13 13 17 (23.5) (20.5) (18.2) (32.0) (22.2) 8 7 6 8 6
Went home directly from the childbirth unit (n ¼37)
physical changes emotional changes breast feeding intimate life the needs of the infant Satisfaction with information I received enough information about I received enough information about I received enough information about I received enough information about I received enough information about
The main findings of this study revealed great discrepancies between women’s SI and PR of postnatal care. There were also differences in the quality assessment between models of care. The most important variables for being ‘very satisfied’ with postnatal care were that the infant got the best possible check-ups/medical care and that the woman received enough support from staff. The discrepancy between women’s evaluation of their experiences of postnatal care and the importance of that aspect of care in this study is interesting, and shows that postnatal care could indeed be better for the questioned variables. Earlier studies have shown that if more than one dimension of care is requested ¨ (Rudman and Waldenstrom, 2007) or if both SI and PR are investigated (Sandin-Bojo¨ et al., in press), women are less satisfied than when asking just an overall question.
Statements about postnatal care
Discussion
Table 3 Quality of postnatal care from women’s perspectives in relation to model of care.
The most important factors for being ‘very satisfied’ with the postnatal care are shown in Table 4. Two variables were related to satisfaction with both the medical and the emotional aspects of postnatal care regardless of parity, namely ‘The infant got the best possible check-ups/medical care’ and ‘I received enough support from the staff ’. Viewing the postnatal stay as too short was related to dissatisfaction with the emotional aspects of care for both primi- and multiparas. Being ‘very satisfied’ with the medical aspects was also related to ‘I received good treatment’, ‘I received enough information about physical changes’ and ‘I received enough information about breast feeding’ in first-time mothers. Information regarding the statement ‘I received enough information about the infant’s needs’ was a strong explanatory factor for mothers with previous children who were also less satisfied with the medical aspects if they viewed the postnatal stay as too long. For satisfaction with the emotional aspects of care in primiparas ‘I received enough information about emotional changes’, ‘I received enough information about the infant’s needs’ and ‘I received good treatment’ were important. In multiparas, ‘I received enough practical instructions about how to take care of the infant’ reached statistical significance. The model of postnatal care was not a contributing factor in any of the studied outcomes.
Traditional postnatal ward (n ¼ 613)
Satisfaction with the medical and emotional aspects of postnatal care
Excess n (%)
Hotel ward (n ¼ 184)
The quality of postnatal care was examined using the created index in relation to the model of postnatal care. There were statistically significant differences for all the studied variables, with the exception of ‘I received enough information about intimate life’ when the models of care were compared (Table 3). Women who went home directly from the delivery unit reported the least balanced care, with deficient care reported for seven out of 10 variables. This was the only group that reported ‘excessive care’ and did so in six out of 10 variables. Women in the traditional postnatal wards, hotel ward and those who had cocare on neonatal wards reported deficient care in all studied variables, and no variable reached 20% in excesses.
Balance n (%)
Women’s assessment of the quality of postnatal care in relation to model of care
Deficiency n (%)
Co-care neonatal ward (n ¼49)
p-Value
received enough information about physical changes’ and ‘I received enough information about breast feeding’, where primiparas rated scores lower compared with multiparas (Table 2).
741
13 (34.2) 4 (10.5) 0.047
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Table 4 Logistic regression model of factors associated with being ‘very satisfied’ with postnatal care. Primiparas OR (95% CI) Medical aspects of postnatal care The infant got the best possible check-ups/medical care I received enough support from the staff I received good treatment I received enough information about physical changes I received enough practical instruction about breast feeding I received enough information about the infant’s needs The hospital stay was too long
Emotional aspects of postnatal care The infant got the best possible check-ups/medical care I received enough support from the staff I received enough information about emotional changes I received good treatment I received enough information about the infant’s needs The hospital stay was too short I received enough practical instruction about how to take care of the infant
Women who went home directly from the delivery unit without staying in the postnatal ward or in the hotel ward reported the least balanced care and differed from women using other care options in terms of reporting ‘less care than needed’ (in seven out of 10 variables) and ‘more care than needed’ (in six out of 10 variables). However, the number of women in this group was small (n¼37). It is not known why women chose to go home directly. One reason could be that they felt that they had more support at home than, for example, in the hotel ward, or that they were not pleased with the care offered, or felt obliged to leave the hospital as soon as possible. The three hospitals under study had different approaches to new mothers. In the smaller hospitals, women could stay on the postnatal ward up to three days after a normal birth, whereas the only option in the large hospital was the hotel ward for this group of new mothers. It is possible that women viewed that option as too narrow, as there was no possibility to get help with the infant during the night, which is one factor identified in dissatisfaction with postnatal care (Hildingsson, 2007; Hildingsson and Thomas, 2007). The finding that the women who went home directly after birth got more care than needed (e.g. excessive care) could probably be explained by their previous experience as the majority of women using this model of care were multiparas with previous experience of a newborn infant and may not have needed more information. Another explanation could be that this group of women went home for other reasons. In the early stages ¨ and Lindmark (1987) pointed out of early discharge, Waldenstrom that women who choose early discharge had a less positive attitude to postnatal care in hospital and greater self- confidence concerning birth and parenthood. Women in the traditional postnatal wards, hotel ward and those who had co-care on neonatal wards reported deficient care in all studied variables and no variable reached 20% in excesses. The reasons for this can only be speculated. One explanation could be that the women’s expectations about postnatal care were too high. One can assume that new mothers have heard stories from their own mothers who were likely to receive a longer stay (five days after a normal birth in 1976), when the infants were taken care of by nannies in special baby units and where the mothers were told to rest and recover after birth. Another explanation could be that the women did not receive enough information about the time following birth during pregnancy; a factor that parents regarded afterwards as unsatisfactory (Kline
2.9 3.6 2.5 2.3 1.8
2.5 5.0 2.5 2.6 2.0 0.2
(1.6–5.4) (1.9–6.6) (1.3–4.5) (1.1–4.9) (1.0–3.2)
(1.1–5.6) (2.6–9.7) (1.25.4) (1.2–5.4) (1.0–3.7) (0.1–0.8)
p-Value
0.001 0.000 0.003 0.020 0.049
0.028 0.005 0.015 0.012 0.038 0.023
Multiparas OR (95% CI)
p-Value
4.38 (2.7–7.0) 5.3 (3.2–8.6)
0.000 0.000 0.000
3.6 (1.9–6.8) 0.2 (0.1–0.6)
0.000 0.001
2.4 (1.4–4.2) 8.0 (4.9–12.9)
0.002 0.000
0.3 (0.1–0.7) 3.7 (1.9–7.1)
0.005 0.000
et al., 1998; Bogren Jungmarker et al., in press). It has, however, been assumed that caregivers perceive pregnant women as less perceptive of issues beyond labour and birth in the antenatal period (Kline et al., 1998). A third explanation for the discrepancies could be related to the length of stay with the intense information given, which earlier studies have also shown (Brown et al., 2002; Hildingsson, 2007). Although the postnatal care was organised differently, the mean time for postnatal care was less than three days. Nevertheless, short postnatal stay after childbirth was implemented for financial reasons, not for the new parents or for security reasons. The result signals that parents do not have the time to adjust to the parental role during the hospital stay. Two variables were related to satisfaction with both the medical and the emotional aspects of postnatal care regardless of parity, namely that the infant got the best possible check-ups/ medical care and the women got enough support from staff. Check-ups/medical care of the infant were important factors in being ‘very satisfied’ with the postnatal care received, which is in accordance with previous studies (Hildingsson et al., 2001; Hildingsson, 2007; Sandin-Bojo¨ et al., 2008). The health and well-being of the infant is one of the most important variables according to women’s views (Geissbuehler and Eberhard, 2002), and worries about the infant’s health have been mirrored in studies reporting that new parents seek care for the infant to a high degree during the first weeks after discharge from hospital after childbirth (Ellberg et al., 2005). However, it is unclear what women actually view as sufficient check-ups/medical care. This should be a subject for further qualitative research. It might be that the profession emphasises check-ups/medical care, and thereby gives the impression that this is more important than anything else. Support from staff was the other factor important for both the medical and emotional aspects of care. Support from staff has previously been reported by parents as a major issue in surveys of postnatal care (Brown et al., 2005; Lindberg et al., 2008; ¨ et al., 2006; Yelland et al., 2007). Previous studies Waldenstrom have shown that with limited personal resources due to lack of midwives or financial restrictions, staff working on postnatal wards perceive the strain and stress of not being able to give the best care (Yelland et al., 2007). It has also been reported that midwives simply do not have the time to give adequate support (Rayner et al., 2008). Early postnatal care in hospital with short length of stay and reduced possibilities for staff to provide
I.M. Hildingsson, A.-K. Sandin-Boj¨ o / Midwifery 27 (2011) 737–744
support could perhaps diminish the staffs’ interest in new mothers. This could make the mothers feel less welcome. It is obvious that the postnatal care has to be changed, although it is still unclear how and what should be changed. This study has several limitations. First, as this was a regional study, the findings can only be generalised to postnatal care in similar areas. Another limitation is that only 53% of those eligible chose to participate in the survey. One explanation could be that people in this area are not approached for research projects in the same way as in more urban areas. Another explanation could be that the women lacked time to complete the questionnaires or that the timing of recruitment (antenatally) for a study of this type (postnatal care) may have had an impact on participation, which was mirrored in the fairly high drop-out rates. The study was also compromised by the exclusion of non-Swedish-speaking women who perhaps have other needs due to cultural and/or health-related issues. It is known from earlier studies that foreign-born women are less likely to participate in parent education classes (Fabian et al., 2004), but are more exposed to ill health during pregnancy and childbirth (Bollini et al., 2009). Another limitation is that the women’s responses provide their subjective views on the issue; there is no evidence of the actual information or care given. In addition, the timing for answering the questionnaire may have influenced the results. The strength of this study lies in its relatively large sample of new mothers. The women included in the study, although all living in one region in Sweden, lived in large cities as well as rural areas. The use of independently completed questionnaires prevents interviewrelated bias. On the other hand, closed-ended questions imply limited options that can hold back responders from answering in greater detail. It is important to distinguish between satisfaction with the actual care given and the importance of various components of care for the individual; the analysis of the index measure combined with SI and PR provide indications of areas where improvement would be valuable.
Conclusion This study adds to the growing literature on postnatal care and thus the lack of satisfaction. Similar factors have previously been reported, such as check-ups/medical care of the infant, length of postnatal stay and support from staff. However, to the authors’ knowledge, no study has incorporated the subjective importance and the perceived reality of the different issues of postnatal care. Asking women/patients about both perspectives adds information when quality aspects are measured and could be recommended for a broader understanding. Further studies are needed to assess the best model of postnatal care that gives the best opportunities to provide satisfactory care for women and their families.
Acknowledgements We thank the women who participated in the study and the midwives who helped in the recruitment process. The study was funded by the Swedish Research Council, the County Council of ¨ Vasternorrland, Mid Sweden University and Karlstad University. References Bluff, R., Holloway, I., 1994. They know best: women’s perception of midwifery care during labour and childbirth. Midwifery 101, 157–164. Bogren Jungmarker, E., Lindgren H., Hildingsson, I., . in press, Playing the second violin is ok—Swedish fathers’ experiences of antenatal care. Journal of Midwifery and Women’s Health.
743
Bollini, P., Pampallona, S., Wanner, P., Kupelnick, B., 2009. Pregnancy outcome of migrant women and integration policy: systematic review of the international literature. Social Sciences and Medicine 68, 452–461. Bramadat, I.J., Driedger, M., 1993. Satisfaction with childbirth: theories and methods of measurement. Birth 20, 22–29. Brown, S., Lumley, J., 1997. The 1993 survey of recent mothers: issues in survey design, analysis and influencing policy. International Journal of Quality in Health Care 9, 265–275. Brown, S., Small, R., Argus, B., Davis, P.G., Krastev, A., 2002. Early postnatal discharge from hospital for healthy mothers and term infants. Cochrane Database of Systematic Reviews, CD002958. Brown, S., Bruinsma, F., Darcy, M.-A., Small, R., Lumley, J., 2004. Early discharge: no evidence of adverse outcomes in three consecutive population-based Australian surveys of recent mothers, conducted in 1989, 1994 and 2000. Paediatric and Perinatal Epidemiology 18, 202–213. Brown, S.J., Davey, M.A., Bruinsma, F.J., 2005. Women’s views and experiences of postnatal hospital care in the Victorian Survey of Recent Mothers 2000. Midwifery 21, 109–126. Carr-Hill, R.A., 1992. The measurement of patient satisfaction. Journal of Public Health Medicine 14, 236–249. ¨ Ellberg, L., Lundman, B., Persson, M.E., Hogberg, U., 2005. Comparison of health care utilization of postnatal programs in Sweden. Journal of Obstetric, Gynecologic, and Neonatal Nursing 34, 55–62. ¨ Ellberg, L., Hogberg, U., Lundman, B., Lindholm, L., 2006. Satisfying parents’ preferences with regard to various models of postnatal care is costminimizing. Acta Obstetricia et Gynecologica Scandinavica 85, 175–181. ¨ Ellberg, L., Hogberg, U., Lindh V., 2008. We feel like one, they see us like two: new parents’ discontent with postnatal care. Midwifery December 10 (Epub ahead of print). ˚ ¨ Fabian, H., Radestad, I., Waldenstrom, U., 2004. Characteristics of Swedish women who do not attend childbirth and parenthood education classes during pregnancy. Midwifery 20, 226–236. Forster, D., McLachlan, H., Yelland, J., Rayner, J., Lumley, J., 2005. PinC. A Review of in-Hospital Postnatal Care in Victoria. La Trobe University, Melbourne. Forster, D.A., McLachlan, H.L., Yelland, J., Rayner, J., Lumley, J., Davey, M.A., 2006. Staffing in postnatal units: is it adequate for the provision of quality care? Staff perspectives from a state-wide review of postnatal care in Victoria, Australia. BMC Health Service Research 4, 83. Geissbuehler, V., Eberhard, J., 2002. Fear of childbirth during pregnancy: a study of more than 8000 pregnant women. Journal of Psychosomatic Obstetrics and Gynaecology 23, 229–235. Hagenfeldt, K., Alton, V., Axelsson, O., 1998. Routine Ultrasound Examination in Pregnancy. SBU-Report No. 139. The Swedish Council on Technology Assessment in Health Care, Stockholm (in Swedish). ¨ ˚ Hildingsson, I., Waldenstrom, U., Radestad, I., 2001. Women’s expectations on prenatal care as assessed in early pregnancy: number of visits, continuity of caregiver and general content. Acta Obstetricia et Gynecologica Scandinavica 81, 118–125. Hildingsson, I., 2007. New parents’ experiences of postnatal care in Sweden. Women and Birth 20, 105–113. Hildingsson, I., Thomas, J., 2007. Processes, problems and solutions: maternity care from the women’s perspective. Journal of Midwifery and Women’s Health 52, 126–133. ¨ Hildingsson, I., Engstrom-Olofsson, R., Thomas, J., Nystedt, A., 2009. Still behind the glass wall? Fathers’ experiences of postnatal care. Journal of Obstetric, Gynecologic and Neonatal Nursing 38, 280–289. Hundley, V., Ryan, M., 2004. Are women’s expectations and preferences for intrapartum care affected by the model of care on offer? British Journal of Obstetrics and Gynaecology 111, 550–560. Kline, C.R., Martin, D.P., Deyo, R.A., 1998. Health consequences of pregnancy and childbirth as perceived by women and clinicians. Obstetrics and Gynaecology 92, 842–848. ¨ hrling, K., Christensson, C., 2008. Expectations of post-partum care Lindberg, I., O among pregnant women living in the north of Sweden. International Journal of Circumpolar Health 67, 472–483. McLachlan, H., Forster, D., Yelland, J., Rayner, J., Lumley, J., 2007. Is the organization and structure of hospital postnatal care a barrier to quality care? Findings from a state-wide review in Victoria, Australia. Midwifery 24, 358–370. Pallant., J., 2007. SPSS Survival Manual. 3rd edn. Allen & Unwin, Sydney. Rothman, K., 2002. Epidemiology—an Introduction. Oxford University Press, New York. Rayner, J.A., Forster, D., McLachlan, H., Yelland, J., Davey, M.A., 2008. A state-wide review of hospital postnatal care in Victoria, Australia: the views and experiences of midwives. Midwifery 24, 310–320. ¨ Rudman, A., Waldenstrom, U., 2007. Critical views on postpartum care expressed by new mothers. BMC Health Service Research 5, 178. ¨ A.-K., Wilde-Larsson, B., Hall-Lord, M.-L., 2008. Women’s perception Sandin-Bojo, of intrapartal care in relation to WHO recommendations. Journal of Clinical Nursing 17, 2993–3003. ¨ A., Wilde-Larsson, B., Berg, M. Kvist, L.J. What is, could be better: Sandin-Bojo, Swedish women’s perceptions of their intrapartal care during planned vaginal birth. International Journal of Health Care Quality Assurance (in press). Sitzia, J., Wood, N., 1997. Patient satisfaction: a review of issues and concepts. Social Science and Medicine 45, 1829–1843. Swedish National Board of Health and Welfare, 2008. Pregnancies, Deliveries and Newborn Infants. The Swedish Medical Birth Register 1973 2006. Official Statistics of Sweden. Socialstyrelsen, Stockholm.
744
I.M. Hildingsson, A.-K. Sandin-Boj¨ o / Midwifery 27 (2011) 737–744
Spurgeon, P., Hicks, C., Barnell, F., 2001. Antenatal, delivery and postnatal comparisons of maternal satisfaction with two pilot changing childbirth schemes compared with traditional model of care. Midwifery 17, 123–132. van Teijlingen, E.R., Hundley, V., Rennie, A.M., Graham, W., Fitzmaurice, A., 2003. Maternity satisfaction studies and their limitations: ‘what is, must still be best’. Birth 30, 75–82. ¨ Waldenstrom, U., Lindmark, G., 1987. Early and late discharge after hospital birth. A comparative study of parental background characteristics. Scandinavian Journal of Social Medicine 15, 159–167. ¨ Waldenstrom, U., Brown, S., McLachlan, H., Forster, D., Brennecke, S., 2000. Does team midwifery increase satisfaction with antenatal, intrapartum and postpartum care? A randomized controlled trial. Birth 27, 168–173.
¨ Waldenstrom, U., Rudman, A., Hildingsson, I., 2006. Intrapartum and postpartum care in Sweden. Women’s opinions and risk factors for not being satisfied. Acta Obstetricia et Gynaecologica Scandinavica 85, 551–560. Wilde, B., Larsson, G., Larsson, M., Starrin, B., 1994. Quality of care. Development of a patient-centred questionnaire based on a grounded theory model. Scandinavian Journal of Caring Sciences 8, 39–48. Wilde, B., Larsson, G., Larsson, M., Starrin, B., 2001. Quality from the Patient’s ˚ ¨ Perspective. [KUPP-boken—Kvalitet ur Patientens Perspektiv]. Vardf orbundet, Stockholm. Yelland, J., Krastev, A., Brown, S., 2007. Enhancing early postnatal care: findings from a major reform of maternity care in three Australian hospitals. Midwifery doi:10.1016/j.midw.2007.01.0040.