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Midwifery (2008) 24, 310–320

0266-6138/$ - sdoi:10.1016/j.m

www.elsevier.com/midw

A state-wide review of hospital postnatal care in Victoria,Australia: The views and experiences of midwives

Jo-Anne Rayner, RN, BNsg, GradDip WomHlth, MWomHlth (Research Officer and PostgraduateStudent)a,�, Della Forster, PhD, RN, RM, BHealthSci (Nurs), (MMid) (Research Fellow and MidwiferyConsultant)a, Helen McLachlan, PhD, RN, GradDip AdvNurs (Mid), MNursStud (Senior Lecturer)b,Jane Yelland, PhD, RN, BAppSc (Research Fellow)a, Mary-Ann Davey, BEd, RN, RM, DipAppSc,PostgradDip Soc (Epidemiologist)a

aMother and Child Health Research, La Trobe University, Bundoora, Victoria, Australia, 3086bClinical School of Midwifery and Neonatal Nursing Studies, La Trobe University, Bundoora, Victoria,Australia�Corresponding author. Tel.: +61 3 8341 8533; fax: +61 3 8341 8555. E-mail address: j.rayner@latrobe.edu.au (J-A. Rayner).

Received 7 July 2006; received in revised form 27 September 2006; accepted 29 October 2006

AbstractObjective: to describe midwives’ views and experiences of the provision and organisation of hospital-based postnatalcare.Design: semi-structured interviews with key informants who provide hospital-based postnatal care.Setting: public hospitals in Victoria, Australia.Participants: clinical midwives and midwifery managers (n ¼ 33).Findings: midwives remain positive about working in hospital-based postnatal care; however, their satisfaction isinfluenced by barriers to effective care beyond their control, which specifically limit the time available to spend withwomen. They described many constraints on their practice, including the length of hospital stay, inadequate midwife-to-woman ratios, the busyness of postnatal units, and the effect of visitors. Midwives viewed the aims of postnatal careto include education and support of women with breastfeeding and parenting skills, and helping in women’s physicalrecovery after pregnancy and birth. Midwives’ perceptions of the factors that influence women’s satisfaction withpostnatal care are consistent with what we know are women’s views: continuity of care, individualised unrushed care,and flexibility in routine practices.Key conclusions and implications for practice: midwives’ views and experiences of hospital-based postnatal care are inaccordance with women’s views and experiences. They are less than satisfied with hospital-based postnatal care, andthey perceive a need for individualised, unrushed, flexible care. With evidence from both providers and women aboutthe unsatisfactory nature of the current provision and organisation of hospital-based postnatal care, new approaches tothis episode of care need to be explored.& 2006 Elsevier Ltd. All rights reserved.

Keywords Postnatal care; Midwives’ views; Key-informant interviews

ee front matter & 2006 Elsevier Ltd. All rights reserved.idw.2006.10.008

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Background

A decade of research examining women’s experi-ences of maternity care in Victoria, Australia, hasfound low levels of satisfaction with the hospitalpostnatal stay (Brown and Lumley, 1993, 1997;Brown et al., 2001). In these studies, women reportless satisfaction with postnatal care compared withantenatal and intrapartum care. Only 50% of thewomen participating in the 2000 state-wide Surveyof Recent Mothers rated their hospital postnatalcare as ‘very good’ (Brown et al., 2001). Thestrongest associations with negative ratings ofsatisfaction were those to do with women’sexperiences of specific aspects of care, especiallythe perceived quality of their interactions withcare providers. Other factors associated withsatisfaction were geographic locality, private ad-mission status, and the women’s country of birth.Rural women were more likely to rate their hospitalpostnatal care as ‘very good’ compared withwomen in metropolitan areas, as were womenreceiving private maternity care compared withthose in the public sector (Darcy et al., 2001). Lessthan one-third of the women participating in aVictorian study exploring Vietnamese, Filipino andTurkish women’s views and experiences of mater-nity care rated their hospital postnatal care as‘very good’ (Yelland et al., 1998). Low levels ofsatisfaction with hospital postnatal care have alsobeen reported in other Australian and internationalstudies (Stamp and Crowther, 1994; Garcia et al.1998; Biro et al., 2000; Waldenstrom et al., 2000;Homer et al., 2002). A recent, qualitative study,exploring women’s views and experiences ofhospital and at home postnatal care in the UK,supports previous research. Women interviewed inthis study felt their hospital postnatal care wasinadequate, did not meet their needs or expecta-tions, with most preferring to go home for rest andsupport (Beake et al., 2005).

In spite of what is known of women’s views ofhospital-based postnatal care nationally and inter-nationally, and the importance of this episode ofmaternity care, surprisingly little is known ofcaregivers’ views of postnatal care. An exploratorystudy of midwives’ views of hospital and communitypostnatal care undertaken by Cattrel et al. (2005)in a North-West British teaching hospital found thatmidwives felt they were not always able to provideoptimal postnatal care. The main themes emergingfrom this study included the priorities in postnatalcare identified as providing women with physicaland emotional support as well as parenting in-formation; the influences of societal expectationson women’s views of motherhood with little

support in the offering; and job satisfaction whichmidwives linked to their ability to provide indivi-dualised care and continuity. Barriers to jobsatisfaction identified by these midwives includedthe increasing time spent on administrative duties,a perceived lack of midwifery staff and not feelingvalued.

Similarly, a study that explored the quality ofbreastfeeding interactions between women andmidwives in two postnatal units in NorthernEngland, found that midwives experiencedorganisational and resource pressures in postnatalcare that influenced their ability to establishrelationships with women in order to meettheir breast-feeding needs (Dykes, 2005). Organisa-tional and resource pressures identified by mid-wives centred largely on a perception thatpostnatal care required less staff than otherareas of maternity care and the constant threatof relocation of staff away from the postnatalunit to another area. We were unable to identifyany other literature or studies that directlyaddressed midwives’ views of hospital-based post-natal care.

A review of postnatal in-hospital care (PinC) inVictorian public hospitals was undertaken in 2004.The overall aim of the review was to document thecurrent organisational structures and proceduresgoverning public hospital-based postnatal care andto record the views of postnatal care providers(Forster et al., 2005).

Aim

The aim of this paper is to describe the views andexperiences of midwives providing hospital-basedpostnatal care in the public sector in Victoria.Midwives make up the largest proportion ofproviders of postnatal care in the public hospitalsector; and it is their views reported here.

Method

The PinC review used a mixed-methods approach,including two forms of data collection: a structuredquestionnaire, which was posted to all publichospitals in Victoria that provide maternity care;and semi-structured interviews with key informantsproviding postnatal care from a selection of thesame hospitals. This paper draws only on the key-informant interviews with midwives about theirviews and experiences of working in postnatal care.Key-informant interviews were chosen as they

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provide rich data from the individual perspective ofthe midwives and allow for clarification anddiscussion of emerging issues (Black, 1994; Fontanaand Frey, 1994; Thorne et al., 1997; Popay et al.,1998).

Before starting the PinC review, ethics approvalwas obtained from La Trobe University, the Victor-ian Department of Human Services, and the 10hospitals that requested additional individualethics approval.

Setting

Victoria is the smallest mainland state in Australia,but has the second largest population at over 5million people (Australian Bureau of Statistics,2005). Most Victorians reside in metropolitan areasclose to the capital city, Melbourne (about 3.4million), whereas the remaining live in regionalVictoria (Australian Bureau of Statistics, 2002).Each year in Victoria, about 63,000 women givebirth. Two-thirds of these women receive theirmaternity care in the public hospital system andthe remainder choose private maternity care (Rileyand King, 2003). Hospital services in Victoria arechiefly provided by public hospitals, funded by thestate government. Victoria has 60 public hospitalsproviding maternity services and another six pro-viding postnatal care only, spread between fiverural and four metropolitan health regions. Birthingin Victoria is concentrated in the metropolitanareas.

Length of stay in hospital after birth is nowshorter than it has ever been, but varies consider-ably between hospitals. Metropolitan non-tertiaryhospitals have the highest bed occupancy, have theshortest length of stay at 2–3 days, and only 20% ofwomen from all hospital locations stay in hospitalfor 4 days or more (Forster et al., 2005). In Victoria,only 43% of hospitals have just midwives providingpostnatal care. Other staff providing postnatal careinclude mothercraft nurses and division one nurses(nurses not endorsed by the Nurses Board ofVictoria to practice midwifery) (Forster et al.,2006). In 1998, the Victorian State Governmentimplemented a package of enhanced maternitycare services, which included improved postnatalcare for women. As part of this package, all womenwere to be offered at least one postnatal visit afterdischarge from hospital (Department of HumanServices Victoria, Maternity Services Program,2003). Most hospitals (61 out of 66) offer womena home visit by a midwife and, in most cases (92%),these visits are provided by hospital midwives(Forster et al., 2005).

Participants

The sampling strategy used to select the keyinformants for the PinC review aimed to provide awide range of views from care providers acrossVictorian public hospitals, to reflect the diversity ofhospital-based postnatal units. For the purpose ofthe review, the hospitals were stratified intofour geographic locations (tertiary, metropolitannon-tertiary, regional or rural). Fourteen hospitalswere chosen from the 66 hospitals providingpostnatal care and invited to participate. Thisincluded the three tertiary hospitals and a sampleof the remaining hospitals, randomly selected;four (of eight) metropolitan non-tertiary hos-pitals; three (of six) regional hospitals; and four(of 25) rural hospitals with more than 100 births peryear. Hospitals selected for the key-informantinterviews were asked in the postal survey tonominate three or four clinicians working inpostnatal care who would be willing to be inter-viewed for the study.

Some hospitals nominated fewer then the re-quested number of key informants and, on occa-sions, key informants were unavailable for ascheduled interview. A total of 38 key-informantinterviews were conducted; 33 with midwivesworking in clinical and managerial roles in post-natal care and five with medical practitionersproviding obstetric care. These interviews enabledthe research team to explore the common anddiverse experiences of midwives providing post-natal care in a range of organisationally andgeographically varied public hospitals.

Data collection

Semi-structured interviews were used to explorethe views and perceptions of key informants of theorganisation and provision of hospital-based post-natal care. The interview schedule was developedfrom the following: issues emerging from analysis ofthe completed PinC review hospital postal survey(first-stage data collection); consideration of theexisting literature on postnatal care; and feedbackfrom the study reference group. A complete versionof the interview schedule is published elsewhere(Yelland et al., 2006). The study reference groupconsisted of clinical midwives, managers of mater-nity units, midwifery academics and consumers,convened for the study as ‘expert’ advisors onissues in postnatal care.

The interviews were conducted betweenAugust and October 2004 by JR, JY and M-AD.Participating hospitals had provided the names

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and contact details of those key informantswilling to be interviewed. Interviews were arrangedat a time convenient to the midwives andconducted on the hospital site. All but two inter-views were conducted face-to-face, with thoseremaining conducted over the telephone. Theinterviews were audio-taped and the averagelength of the interviews was 50mins. Writteninformed consent was obtained before startingthe interviews, and a copy of the consentform was left with each key informant. To maintainconfidentiality and anonymity, each hospitalparticipating in the PinC review was allocated aunique identifier (ID). Key informants were assuredthat none of their comments could be ascribed tothem, and each key informant was assigned anadditional numerical ID adjoined to that allocatedto hospitals.

Data analysis

The interviews were transcribed verbatim, withall identifying information about hospitals orindividuals omitted from the transcripts. Eachtranscription was carefully checked against theaudio-tapes by one of the authors (JR) for tran-scription errors or omissions. This provided theresearcher with an in-depth understanding of thedata, and enabled a more accurate and completedescription of the issues for midwives working inpostnatal care.

The analysis process was inductive, meaningpatterns and themes emerged from the transcriptsof interviews with midwives (Patton, 1990). Eachtranscript was read and re-read by the researchteam, and discussion then undertaken aroundunderstanding, interpretation and integration ofemergent basic themes. A thematic networkwas used to connect categories (issues raised inthe postal survey that guided the interview ques-tions) with emerging basic themes and quotes(Attride-Stirling, 2001). Data analysis proceededwith basic themes fully explored and coded in eachtranscript, similarities in codes compared, andbasic themes collapsed under organisational themeheadings. Thematic development was discussedbetween all team members. Inter-coder reliabilitywas checked in 10% of the sample between teammembers and any disparities were settled byconsensus. Quotes were selected and edited (San-delowski, 1994) with the purpose of reflecting themajor emergent themes. Selected quotes wereidentified by key informant ID and the type ofhospital category.

Findings

The findings presented in this paper are the viewsof midwives who provide postnatal care in publichospitals. Themes emerging from four intercon-nected interview categories will be presented:midwives’ views of the aims of postnatal care;midwives’ perceptions of women’s satisfaction withpostnatal care; organisational barriers to midwiferypractice, and postnatal care in an ideal world.

The 33 midwives interviewed represented hospi-tals participating in the review: eight providedpostnatal care in tertiary hospitals; nine in me-tropolitan non-tertiary hospitals; nine in regionalhospitals; and seven in rural hospitals. All themidwives interviewed were women. They hadconsiderable experience working in hospital mater-nity service provision: 29 had worked in maternityservices for more than 10 years and 26 worked full-time. Twenty-five midwives combined clinicalpostnatal care with a managerial role: 11 workingas midwifery unit managers and 14 as associate unitmanagers. Eight were clinical midwives.

Midwives’ views of the aims of postnatal care

Midwives are the main providers of hospital-basedmaternity care, and postnatal care is no exception.In theory, the aims or intentions of each particularepisode of maternity care guide midwifery prac-tice. In the key-informant interviews, midwiveswere asked to talk about their perceived aims ofhospital-based postnatal care, with a view toidentifying and defining the goals that guideindividual practice. There was a great deal ofconvergence and accord among midwives in theirresponses to this question, and three themesemerged as primary aims of postnatal care. Themost significant of these was education of newmothers, which included information and supportwith breastfeeding and parenting skills.

Two-thirds of midwives felt one of their primaryroles during the postnatal stay was to educatewomen about breastfeeding and to provide themwith information and support in this activity.Included in their role perception was the offeringof practical help to women with aspects ofattachment and positioning of the baby duringbreastfeeding, as well as providing emotionalsupport and encouragement to breastfeed. Two ofthese midwives mentioned in ‘hushed tones’ thatsome women chose to bottle feed their baby, and,although they acknowledged this as a woman’sright, there was a general commitment to breast-feeding as the appropriate and ideal feeding choice

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for mother and baby alike. Discussions about thetype and scope of information women requiredduring the postnatal stay included the physiologicalnature of breastfeeding, the benefits to women andtheir baby, the possible issues that might arise, andthe availability of services on discharge fromhospital.

The responses about the central role of midwivesin the provision of breastfeeding education andsupport to women were strongly and enthusiasti-cally expressed. The language used also conveyedan understanding of women’s individual experi-ences as being salient in this process. Midwives alsogave voice to the complexities of learning newmothering skills, suggesting that breastfeeding forsome women was ‘not easy’, and assistance andencouragement were required, especially for first-time mothers. Common responses about breast-feeding education and support included:

The biggest, biggest, biggest thing is always thebreastfeeding. (KI 1048-1, Tertiary)

To get them ready to go home, to be informedand educated and confident breastfeeding. (KI1023-2, Regional)

In responding to this issue, midwives alsodemonstrated an awareness of the importance ofwomen’s comfort with and enjoyment of breast-feeding:

If she’s breastfeeding to make sure that she’scomfortable with breastfeeding and confidentwith putting the baby on independently. (KI1048-2, Tertiary)

Educating women in parenting skills was alsohighlighted by two-thirds of the midwives as aprimary aim of postnatal care. Parenting skills,especially for first-time mothers, were discussed inthe context of ensuring women were well-preparedto go home, confident and capable in the care oftheir baby. Practical skills again featured in discus-sions, such as baby settling techniques, nappy care,and bathing of newborn babies. Midwives notedthat, in contemporary Australian society, manywomen have never handled or observed a new babybefore having their own. The importance ofinvolving family members, especially partners andsiblings, in parenting education was also discussedwithin the social context of contemporary parent-ing:

I think the main aim is to prepare that family forsomething, especially first time mums, that youcannot imagine what it’s like. (KI 1035-1,Tertiary)

Just to prepare the woman for caring for herbaby, encouraging her to be independent withthe care of her baby and just educating her in allthe different things that she needs to knowabout parenting. (KI 1036-1, Rural)

Linking women to community supports andresources was considered part of the postnataleducation that midwives provided. They felt it wasimperative to inform women about what supportservices are available for them and their baby oncedischarged from hospital:

The aims of postnatal care would be to alsoinform them of all their support so that whenthey do go home, that link between the hospitalbased and home [so] that they’re able to supportthemselves in the event of any emergency. (KI1053-4, Tertiary)

Aiding women’s physical recovery from preg-nancy and birth was discussed by one-third of themidwives responding as another aim of postnatalcare. Related to their educative role, midwivesspoke of promoting maternal health and theimportance of educating and informing womenabout normal physiological changes to their bodiesafter birth and breastfeeding. Pregnancy and birthwas viewed as a normal life stage for women, buteducation included enabling women to identify anyhealth problems, such as mastitis or a woundinfection that may arise after discharge. Seven ofthese midwives were more specific with theirresponses about maternal health and recovery,suggesting awareness and identification of post-natal depression as a significant aspect of women’seducation during the postnatal stay:

Before a woman goes home we want to makesure that she’s aware of what normal physiolo-gical changes take place and be aware of how topick up if there’s any infection. (KI 1020-1,Regional)

Day three, we put a big emphasis on signs ofpostnatal depression, [and] we encourage mumsto stay as long as they can. (KI 1040-2, Rural)

Providing women with an opportunity to rest inthe postnatal period was the third aim of careraised, and seven midwives saw their role asnurturing women as part of recovery at this time.They suggested labour and birth were transforma-tive and occasionally traumatic for women, andthat the hospital postnatal stay should providesome recognition of this. These midwives spokeabout the hospital postnatal stay as a time forwomen to celebrate motherhood, be nurtured, and

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enjoy the early postnatal experience with theirfamily:

I’m very strong in women’s health and I believethat nurturing a woman after having her baby isparamount, and that’s really eroded because youdon’t have that time to actually tuck someoneinto bed and you say, ‘You feel lousy, I’ll lookafter your baby and look after you’ and makesomeone feel very safe and get them better. (KI1046-3, Tertiary)

It is just to support the mother and her baby andher family at this very special time, and it’s anexperience that they will always remember. (KI1020-1, Regional)

Midwives’ perceptions of women’s satisfactionwith postnatal care

One of the reasons the PinC review was undertakenwas that women have repeatedly rated theirpostnatal care as less satisfying than other episodesof maternity care. Midwives were asked to describewhat they considered were the key aspects ofwomen’s satisfaction. Three themes emerged:interactions between staff and women; women’sperceptions of postnatal care; and the physicalpostnatal environment.

Midwives overwhelmingly (30 out of 33) re-sponded that the day-to-day interactions withwomen were paramount in women’s satis-faction with the postnatal experience. Theyacknowledged the need to be friendly and listento women no matter what their parity or howtrivial their concerns seemed. Communication withwomen needed to be clear and concise, and womenneeded to feel midwives were genuinely inte-rested in engaging with them. The need for midwifetime with individual women for education wasstressed, especially those experiencing pro-blems. Empowering women in their own care andwith decisions regarding their baby was alsoemphasised:

Well I think that being listened to and I think it’sjust so important to [treat them] like they’re anindividual mother and baby. (KI 1020-1, Regio-nal)

Probably how they’re approached by staff, theinteraction, and the time that they spend withthe woman. (KI 1035-3, Metropolitan non-ter-tiary)

Women’s satisfaction with postnatal care wasdescribed by midwives as being linked to organisa-tional issues in the provision of care, such as

continuity of care; the routine nature of somepractices such as postpartum observations; andwhether there was flexibility to allow for a moreindividualised approach to care. Continuity ofadvice was mentioned by two-thirds of midwivesas central to women’s satisfaction with postnatalcare:

I think they appreciate it when there iscontinuity of care and I think if there’s someonewho’s not particularly happy, often that’sbecause there’s been conflicting advice,which doesn’t happen that often fortunately.(KI 1011-3, Metropolitan non-tertiary)

From my experience from what women say, it’shaving [a] midwife that they know to delivertheir postnatal care, that’s really important towomen because a lot of them say that when theysee different faces, they get lots of differentinformation. (KI 1053-4,Tertiary)

The final aspect of women’s satisfaction withpostnatal care, as perceived by midwives, re-lated to the physical environment of the postnatalunit. More than two-thirds of the midwivesthought that postnatal units were busy, oftenchaotic places not conducive to rest or education.Women were often in shared rooms with constantnoise and visitors. Providing a restful environmentwas seen as conducive to improving women’spostnatal experience. Although the midwives couldidentify the issues affecting women’s satisfaction,they also conceded there were not always easysolutions:

I would think number one would be rest, sleep,and you know, they talk about baby-friendlyhospitals, but some of the mums screamed at us,‘Well, when are we going to get mother-friendly?’ Far too many visitors, really longdrawn out visiting hours, but you’ll be a braveperson if you challenge that, from the commu-nity point of view. (KI 1012-1, Regional)

Organisational barriers to postnatal care

Responses to midwives’ views of the aims ofpostnatal care in most instances included a lengthydiscussion about the many barriers to achievingthem. Half the midwives responding talked aboutthe reality of organisational issues in the provisionof postnatal care including: the length of thepostnatal stay for most women; the busyness andchaotic nature of maternity units; the inadequacyof staffing especially at night; and the effect large

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numbers of visitors had on postnatal education andcare:

So there’s a heck of a lot of issues, andunfortunately, I think that the postnatal comesdown as being a poor cousin to the others.(KI 1012-1, Regional)

These midwives cited the short length of thepostnatal stay as reducing their ability to educatewomen and provide them with information andsupport. They expressed frustration at not beingable to fulfil their professional role in caring for andeducating women in an optimal manner after birth,especially if women had not established lactation.The length of stay was also seen to reduce theopportunity for maternal rest and recovery, andsome midwives expressed their anxiety in sendingwomen home with little time to recover. The busynature of maternity units was not only attributed tothe length of stay but was seen to be exacerbatedby inadequate staffing and unrestricted visitinghours:

I think the aims have changed very much in thelast few years with the shortened length of stay.I can’t say that we have the breastfeeding issuesall sorted out because most of these girls [sic] gohome before their lactation has established. (KI1012-1, Regional)

Bonding for the mum and education and breast-feeding is the highest one. [It] is difficult in thatshort period of time and they’re mainly tired. (KI1035-3, Tertiary)

The most frequently discussed staffing issueraised by these midwives was the inadequacy ofthe midwife-to-women ratio at night. They high-lighted that women’s and babies’ needs did notlessen because of a change in shift or the movefrom day to night; rather, they often increased,exacerbated by a busy and tiring day. A secon-dary staffing issue in postnatal units discussedby these midwives was the prioritising of otherareas over postnatal care. Midwives could bemoved from the postnatal unit to other areas ofmaternity care, most often birth suite, or evenother non-maternity areas within the hospitalthat were busy or short staffed. The midwives feltthat postnatal care was generally viewed byhospital administration as an area that requiredminimum staff as women were generally well.Hospital-based postnatal care was identified by onemidwife as being acute care provision, or ‘thepractical ritualistic nursing care of hospitals’ (KI1053-2, Tertiary), rather than the education and

supportive role that midwives prefer to provide inpostnatal care :

With the postnatal care often on night shift thestaff feel stressed and actually if birth suite isbusy, they’re actually pulled, and so sometimesone midwife might be left looking after I don’tknow, sixteen mothers and babies. (KI 1020-1,Regional)

Sometimes the staffing levels aren’t adequate,and quite often management look and say, ‘Oh,alright, you’ve got spare beds’, so you know,people that need surgery are just allocated, andthey’re not looking at the overall picture, you’vegot to provide a safe environment for the staffand the patient. So quite often there’s a battlewith management to provide a safe environmentfor the mothers and their babies, and the staff.(KI 1020-2, Regional)

Linked to the issue of the busyness of postnatalunits, was the effect of visitors and often unrest-ricted visiting hours during the postnatal stay. Themidwives felt visitors not only limited and inter-rupted the time they had to educate women duringthe postnatal stay but they reduced women’sopportunity to rest and recover after birth.Prolonged visiting hours and the volume of visitorswere frequently mentioned:

We’ve been very strict on visitors because it was‘a free for all’ for a long time. They’d come in,[and] we’d find women breastfeeding in thetoilets. So I did an audit and found the womenwanted it and we do that. (KI, 1062-2, Metropo-litan non-tertiary)

In the context of the barriers to providingpostnatal care, midwives were asked about theirprofessional and personal satisfaction working inthis area. Two-thirds of them were positive aboutworking in postnatal care. Factors associated withtheir satisfaction were working with well womenand the collegiality between midwives. The sharedprofessional goals of educating and caring forwomen and babies, which contributed to satisfac-tion and longevity in the area. Being able to providehigh-quality postnatal care with a degree ofprofessional autonomy was also central to mid-wives’ satisfaction with working in the area:

The rapport with the staff on [name of postnatalunit] is fantastic. We work really well as a team,we understand one another really well, and Ithink we provide really, really good care. Wehave much more say over what goes on with thewomen, and the medical staff will on the whole,listen to us and that’s one of the reasons why I

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wouldn’t work there [delivery suite]. (KI 1048-2,Tertiary)

For three midwives, particularly in rural hospi-tals, the enjoyment of working in postnatal carewas associated with reaching the end of a mid-wifery career. No longer feeling able to meet thedemands of working in birth suite, they acknowl-edged that, although postnatal care was stillchallenging, it was perhaps a less physically intensework environment:

I do [like working in postnatal]. I must admit atthis stage of my career and my life, my career isprobably coming towards an end, although I’mnot prepared to give up yet, I would certainlychoose postnatal. I think it needs propping upand I do get a lot of satisfaction from working inthat area. (KI 1012-1, Regional)

Six midwives were ambivalent about working inpostnatal care, whereas three preferred working inthe birth suite. Ambivalent responses most oftencame from midwives working in (or those whowould like to work in) a maternity model of carethat allowed them to work across all areas.

Postnatal care in an ideal world

Midwives were asked to describe their vision ofpostnatal care in an ideal world. They wereencouraged to think about how they would struc-ture a postnatal unit, how they would organisecare, and what resources they considered would beimportant to achieving optimum postnatal care.Overall, responses focused on the importance ofproviding individualised postnatal care to women.It was suggested this could be achieved by a moreflexible length of stay, tailored to individualwomen’s needs and requirements; adequate mid-wife-to-women ratios in postnatal units and noreduction in staffing numbers at night; careprovided only by midwives; improved physicalfacilities in postnatal units that would providewomen with comfort and privacy; and strategies toincrease women’s rest and continuity of care.

Half the midwives responding commented thatin an ideal world the hospital length of stay shouldbe flexible. Although some midwives had citedthe length of stay after birth as a barrier toachieving the aims of postnatal care, most mid-wives responding suggested women would bebetter discharged home early after birth withadditional domiciliary visits, day and night. Givingwomen the choice to stay in hospital or go homewith midwifery care was seen as a more favourable

option for women and would better achieve theaims of postnatal care:

I’d like to do it at home. I’d like them to go homeand be able to offer them the service. Then havesomeone there and send them straight home anddo it all at home and someone available over-night. That’s the ideal for me. (KI 1023-1,Regional)

I think I would have more flexibility in the lengthof stay. I wouldn’t necessarily say that that’salways ideal, I think sometimes it’s good forwomen to go home. (KI 1011-3, Metropolitannon-tertiary)

Half the midwives also described the need toimprove the physical environments of postnatalunits for women and staff alike, especially if lengthof stay was to remain unchanged. Suggestionsincluded single rooms for all women to increasethe opportunity for rest, so that partners could stayovernight and to maintain privacy. The idea of acommon room in postnatal units was also sug-gested. A space for families to gather, for staff tohold communal education sessions and wherewomen could interact with each other was seenby some midwives as an ideal option for hospital-based postnatal care:

Well I guess I’d just like it to be for womenand babies, and certainly no more than two ina room, and that there was an area wherethey could go with their families. (KI 1020-1,Regional)

In an ideal world, one-third of the midwives alsowanted more midwives in postnatal care provision,suggesting better midwife-to-women ratios wouldenable midwives to have more time with individualwomen to improve outcomes such as breastfeedingand women’s satisfaction with care. Recognition ofthe importance of the postnatal period for womenand respect for the professional skills of midwiveswas implicit in many responses:

I probably [would] have at least one midwife toevery three patients. I think that would bebetter ratio. How the hell can you actuallyestablish breastfeeding when you’ve got fourbells ringing. (KI 1012-1, Regional)

More staff to women available, more importanceplaced on that period of time by management.(KI 1035-3, Metropolitan non-tertiary)

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Discussion

Compared with the antenatal and intrapartumepisodes of care, the postnatal stay in hospital ischaracterised by a dearth of evidence and complexorganisational issues that affect the provision ofcare by midwives. The PinC review identified agreat deal of diversity in the provision of hospital-based postnatal care across Victoria in relation tomodels of care, staffing arrangements, and physicalfacilities at the hospital level. Diversity in routinepostnatal care practices was also found amongmidwives (Forster et al., 2005). Despite this,midwives were overwhelmingly enthusiastic about,and committed to, providing the highest qualitypostnatal care despite a strong sense that it wasconsidered of lower priority, or the ‘poor cousin’compared with other episodes of maternity care.

In this paper, we have described midwives’ viewsand experiences of providing hospital-based post-natal care. Midwives who work in public hospitalpostnatal units had shared views about the role ofmidwives in the provision of postnatal care;however, they were frustrated by organisationalissues beyond their control that affect their abilityto achieve this.

Midwives described the aims of postnatal care tobe educating and supporting women with breast-feeding and other parenting skills to equip them forgoing home; helping women recover physicallyfrom the birth; and nurturing them in a time ofphysical, emotional and social transition. These aresimilar to the priorities identified by midwives inthe study by Cattrell et al. (2005).

The ability of midwives to provide optimumpostnatal care, however, needs to be consideredin light of the effect of competing client demandsand organisational pressures beyond their control.Barriers to the provision of postnatal care wereraised repeatedly by midwives. Midwives expressedfrustration at the limited time they had to supportand educate women in a caring relationship. Thebusyness of postnatal units, inadequate midwife-to-women ratios, and interruptions to women’s restby visitors were all issues raised by midwives asbarriers to satisfactory postnatal care provision. Alack of comparative literature makes it difficult toextrapolate these issues more generally. BothCattrell et al. (2005) and Dykes (2005) found staffmorale and job satisfaction in midwifery wasaffected by staffing levels, working relationshipsand organisational issues. British midwives in bothstudies expressed a lack of relationality with thewomen they cared for in postnatal units because oforganisational pressures such as time, inadequatestaffing and a divergent view of practice roles

between midwives and hospital management.These findings are consistent with the findings ofour study.

Similarly, Cloherty et al. (2004), in exploringmothers’ and health-care professionals’ beliefs,expectations and experiences in relation to supple-mentation of breastfeeding during the postnatalstay found enabling midwives to support (oftentired) mothers to establish breastfeeding requiredtime, and staff were often not available. As aresult, some midwives made pragmatic decisions tosuggest or accept supplementary feeding despitetheir commitment to breastfeeding. However, thiswas not supported in the PinC findings, wheremidwives cited breastfeeding as the primary aim ofpostnatal care.

The short postnatal length of stay emerged in thekey-informant interviews as a barrier to achievingthe aims of care and, paradoxically, as a desirableaspect of postnatal care in an ideal world. Findingsfrom the PinC review showed length of stay variedconsiderably across hospital geographic locations.Length of stay in hospital after birth was also afactor associated with women’s satisfaction withpostnatal care in the most recent state-wide surveyof recent mothers. Women staying in hospital foronly one or two days reported less positive ratingsof care compared with the views of women whostayed five days or more (Brown et al., 2005). Wattet al. (2005) found offering women with uncompli-cated births a longer length of stay improvedwomen’s satisfaction with the hospital experience,even if they did not take up the offer to stay longer.Providing women with some choice and control orindividualising their postnatal care may be moreimportant than the actual length of hospital stay.Midwives participating in the PinC review inter-views suggest flexibility in the length of stay asbeing important to women’s satisfaction with careand midwives’ professional fulfilment.

The key-informant interviews suggest that mid-wives understand the factors relevant to women’ssatisfaction with their hospital-based postnatalcare. The issues put forward by midwives, such asstaff taking time when interacting with women,friendly consistent advice, and empowering womenin decision-making are almost identical to thoseexpressed by women in an earlier study by Brown etal. (2005). Similar issues were discussed by Beakeet al. (2005). Women expected more support duringtheir in-hospital postnatal care than they received,and the environment was not conducive to rest. It islikely that the effect of organisational issues inpostnatal care is pivotal to women achievingsatisfaction with postnatal care. The interviewswith midwives suggest postnatal units are busy and

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not conducive to quiet productive encountersbetween staff and women. The length of hospitalstay, the possible inadequacy of midwife-to-womanratios, and movement of staff to areas deemedof higher need, reveals the low priority ofpostnatal care in the management of maternitycare provision.

Despite the hectic nature of postnatal units,midwives participating in the key-informants inter-views for the PinC review mostly enjoyed workingin postnatal care and were committed to deliveringhigh-quality care. Satisfaction with working inpostnatal care for midwives was achieved throughworking in a stimulating team environment thatprovided them with the opportunity to use theirexpertise in educating and supporting women andtheir families. Many midwives, however, suggestedthat postnatal care could be organised to bettersuit the aims of care and increase women’ssatisfaction. They responded enthusiastically withideas for postnatal care in an ideal world.

The responses of midwives reported in this studymay have been influenced by the process ofselection. Potential key informants were selectedby hospital survey respondents, which may haveintroduced a selection bias in the recruitment ofkey informants. The research team had no controlover which midwives were asked to participate inthe interview. However, undertaking multiple inter-views at the same hospital may have helped reducethe opportunity for bias, and randomly selectinghospitals to participate in the key-informant inter-views across all hospital geographic locations islikely to generate more informationally generali-sable views of postnatal care.

Conclusion and implications for practice

Midwives interviewed in the PinC review suggestedpostnatal care needs to become more woman-centred, with care tailored towards individualneeds. Ideally, midwives would like more time withwomen to achieve the aims of care, which theyconsider would increase women’s satisfaction andfulfil their own professional role. Suggestions frommidwives included increased flexibility in thelength of the hospital stay after birth, in combina-tion with a package of hospital-and home-basedpostnatal care.

Midwives reported that staffing remains a pro-blem in many postnatal units. Staff levels do notreflect the special needs of many women, andmidwives feel managers and health-service policymakers failed to recognise that the time spent inhospital after birth requires intensive midwifery

care, especially in the provision of breast-feedingsupport. The provision of education, informationand supportive care during the hospital postnatalstay require both midwife time and resources.

We have some understanding of what womenconsider a satisfactory episode of postnatal carefrom previous research, including friendly, respect-ful and helpful interaction with midwives whomthey know. It seems women’s views coincide withwhat we now know of midwives’ views andperceptions of postnatal care. As evidence is nowavailable and consistent about the factors thatinfluence women’s satisfaction with hospital-basedpostnatal care, new approaches to the provisionand organisation of this episode of maternity careneed to be explored.

Acknowledgments

The state-wide review of postnatal care was fundedby the Telstra Foundation’s Community De-velopment Fund and the William Buckland Founda-tion. Thank you to all those midwives who tookpart in the interviews for the PinC review,which form the basis of this article; to Serenafor the transcription of interviews; to all careproviders who took part in the PinC review; tomembers of the reference group who provideduseful insights and feedback; and to ProfessorJudith Lumley and all our colleagues at La TrobeUniversity.

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