Midwifery 29 (2013) 159–166

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Midwifery

0266-61

doi:10.1

n Corr

E-m

journal homepage: www.elsevier.com/midw

Redesigning postnatal care: exploring the viewsand experiences of midwives

Jane Morrow, RM, B Hth Sci (Nursing), MHealth Management, Grad Dip Teachingand Learning (Senior Lecturer)a,n, Helen McLachlan, BNurs, Post Grad Dip Adv Nursing (Mid), MNurs,PhD (Associate Professor)b, Della Forster, Dip App Sci (Nursing), BHealth Sci (Nursing), MMid, PhD(Professor of Midwifery & Maternity Services Research)c, Mary-Ann Davey DPH, MEpi, Grad Dip Soc,BEd, Dip App Sci (Senior Research Fellow)d, Michelle Newton Grad Dip App Sci (Nursing), Post Grad DipHealth Ed, MMid (Lecturer)e

a School of Nursing and Midwifery, Australian Catholic University, 115 Victoria Pde, Fitzroy, 3065, Australiab School of Nursing and Midwifery/Mother and Child Health Research, La Trobe University, Bundoora 3086, Australiac Mother and Child Health Research, La Trobe University & Royal Women’s Hospital, 215 Franklin St, Melbourne 3000, Australiad Mother and Child Health Research, La Trobe University, 215 Franklin St, Melbourne 3000, Australiae School of Nursing & Midwifery, La Trobe University, Bundoora 3086, Australia

a r t i c l e i n f o

Article history:

Received 27 September 2011

Received in revised form

7 November 2011

Accepted 13 November 2011

Keywords:

Postnatal care

Midwives views

Documentation

Guidelines

38/$ - see front matter & 2011 Elsevier Ltd. A

016/j.midw.2011.11.006

esponding author.

ail address: jane.morrow@acu.edu.au (J. Morr

a b s t r a c t

Objective: women have consistently rated postnatal care less favourably than other episodes of

maternity care. Midwives have also reported concerns with postnatal care, with challenges related to

workloads, busy environments and lack of staff. Given these concerns, a regional hospital in Victoria,

Australia redesigned its postnatal care provision. The changes included cessation of routine postnatal

observations and the use of clinical pathways for women who gave birth vaginally; promotion of rest

through minimal disturbances before 9 am; discouraging the use of the call bell system except in

emergency situations; introduction of ‘one-to-one’ time with women; and promotion of normalcy and

independence. This paper examines midwives’ views of the changes and their impressions of the effects

of the changes on women and their infants.

Design: cross-sectional surveys of midwives were conducted six months after the changes to postnatal

care were introduced then again, two years later. Midwives’ views and experiences of the changes; the

impact of the changes on confidence and autonomy of practice; views regarding the effect on women’s

satisfaction with care; and the perceived safety of the changes were explored.

Setting: a regional hospital in Victoria, Australia where approximately 2,000 births occur each year.

Participants: permanent part-time and full-time midwives.

Findings: response rates were 64% (50/78) at baseline and 60% (50/84) two years later. Overall,

midwives were supportive of, and complied with, the changes to postnatal care. They agreed that

change was needed and believed that the new way of providing care would be better for women and

increase individualised care. Midwives also agreed that the changes would facilitate rest for women,

believed that removal of routine observations for women after a vaginal birth was safe and that it

would allow more time with women. Over time, midwives were more likely to feel autonomous when

providing postnatal care. However, some concerns were raised, mostly in relation to the challenges

around postnatal documentation, care provision without the guidance of a care/clinical pathway, and

about limiting the use of the call bell to only emergency situations. Midwives were not confident that

the changes would necessarily translate to a measurable increase in women’s satisfaction with care,

and were not confident that the changes translated into more time to spend listening and providing

support to women.

Key conclusions and implications for practice: overall, midwives were supportive of the changes and agreed

that change to postnatal care was needed. Challenges remain around the most effective method of

ll rights reserved.

ow).

J. Morrow et al. / Midwifery 29 (2013) 159–166160

communication and documentation of postnatal care. It is important that when major changes to care

provision are implemented that care providers’ views and experiences are explored given their crucial role

in the introduction and maintenance of changes and the potential impact on them as care providers.

& 2011 Elsevier Ltd. All rights reserved.

Introduction

Increasing concerns have been reported about the quality andeffectiveness of postnatal care from the perspectives of bothwomen (Garcia et al., 1997; Singh and Newburn, 2000; Brownet al., 2005; Waldenstrom et al., 2006; Newburn and Bhavnani,2010) and care providers (Cattrell et al., 2005; Forster et al., 2005).At the same time, there has been a lack of evidence to guidepostnatal care (Schmied et al., 2008), yet few studies haveattempted to implement and evaluate interventions aimed atimproving postnatal care.

State-wide surveys of recent mothers conducted over the pasttwo decades in Victoria, Australia have found that women con-sistently rate the care they receive in hospital following birth lessfavourably than antenatal or intrapartum care (Brown andLumley, 1993, 1997; Brown et al., 2001). Other studies, particu-larly from Australia (Biro et al., 2000; Waldenstrom et al., 2000;Homer et al., 2002; Brown et al., 2005), the United Kingdom(Garcia et al., 1997; Hicks et al., 2003; Beake et al., 2005;Newburn and Bhavnani, 2010) and Sweden (Rudman andWaldenstrom, 2007) have reported similar findings in relationto women’s satisfaction with care, and recommended that post-natal care could be improved. In the state of Victoria, Australia,factors associated with lower ratings of satisfaction include ashorter length of stay; not having continuity of midwife carer;limited opportunity to rest; lack of sensitivity of caregivers, theextent to which concerns and anxieties are taken seriously; howrushed caregivers seem; the helpfulness of advice and support;and whether help and advice are offered (Brown and Lumley,1993, 1997; Brown et al., 2005).

Midwives have also expressed dissatisfaction and problemswith postnatal care provision. A 2004 Victorian state-wide reviewof hospital postnatal care from the perspective of care providersidentified a number of barriers to care provision including thebusyness of postnatal wards, inadequate staffing, and staffingpriority being given to other areas of maternity services(McLachlan et al., 2008). Despite this, midwives were positiveabout providing postnatal care, but felt that time to provide carewas limited due to the short length of stay, the effect of visitors,the midwife-to-women ratios, and the busy hospital environment.Similar concerns have been identified in the United Kingdom.Cattrell et al. (2005) found that midwives were not able to provideoptimal postnatal care due to a lack of staff and time spent on non-midwifery tasks and that they did not feel valued in their role.Dykes (2005) explored the breast feeding needs of women andfound that midwives considered that staffing of the postnatal areawas often under threat, with staff being moved to other areaswhich made it difficult to provide adequate breast-feeding support.

In 2006 the National Institute for Health and Clinical Effec-tiveness (NICE) in the United Kingdom published guidelines forpostnatal care (NICE, 2006). These guidelines aimed to standar-dise care, reduce variations in patient outcomes, discourage theuse of interventions that have no proven benefit and encouragesystematic assessment of patient outcomes (Bick and Graham,2010). Although the NICE guidelines were based on the bestavailable evidence, the authors acknowledge that there werelimited high level studies to inform the guidelines.

In Australia, clinical pathways (care maps) are used exten-sively and are the main form of documentation used to recordpostnatal care, despite a lack of evidence for their use in

maternity care (Savage, 2008). A state-wide review in Victoriafound that 94% (62/66) of hospitals used care maps for postnataldocumentation, however most were of poor standard, few con-tained references and most were appraised as relatively lowquality overall (Savage, 2008).

Few studies have attempted to implement and evaluate inter-ventions aimed at improving postnatal care. An Australian studyimplemented postnatal changes that were developed by mid-wives who provided postnatal care, using an action research cycle(Schmied et al., 2009). The changes included providing ‘one-to-one’ time with women, where the midwife caring for the womanwas encouraged to provide uninterrupted time to listen to thewoman and address her worries and concerns, attempting toindividualise care. Overall, ‘one-to-one’ time was inconsistentlyimplemented and a number of aspects of women’s experiences ofpostnatal care remained unchanged; however women whoexperienced a health issue rated their care more positively thanwomen who did not and were more likely to report having beengiven advice and assistance to rest (Schmied et al., 2009).

Given the concerns from both women and care providersregarding postnatal care provision and in light of the publicationof the NICE guidelines for postnatal care (NICE, 2006), BarwonHealth (a regional public hospital in Victoria, Australia with 2,000births per year) introduced major changes to its postnatal careprovision in 2008.

Description of changes and change process

A consultation process was undertaken with all relevant staffincluding midwives, medical staff, and managers. Evidence citedin the NICE guidelines was presented to staff and discussion on‘where to’ with postnatal care was facilitated. The consultationincluded a process mapping exercise to gain an understanding ofthe potential impact of any changes on staff and women. Thisconsultation resulted in the development of three key aims: toprovide a more flexible, individualised approach to postnatalcare; to reorientate care to focus on the postnatal period as‘normal’; and to revise and improve documentation of care.

To promote individualised care and focus on normalisation of thepostnatal period, the changes included ceasing routine observationson women and babies following a vaginal birth, including vital signssuch as temperature and pulse measurement, checking of theuterine fundus, perineum checks for signs of healing and breastchecks, which were previously performed daily following admissionto the postnatal ward until discharge home usually following a twonight stay. Additionally, mothers were invited to self cater forbreakfast in a communal kitchen; encouraged to access their ownclean linen and other provisions such as clean nappies; and asked touse the call bell only in urgent situations. Rest was promoted, withno unnecessary disturbances of women before 9 am.

Prior to any changes to postnatal care at Barwon Health, theclinical pathway was the main document that guided both careand documentation throughout the postnatal episode. Oncechanges were introduced, individualised care plans were to bewritten with each woman, underpinned by the NICE guidelines.All care providers were directed to document care on progressnotes contemporaneously with care provision, with deviationsfrom expected ‘normal’ progress documented as variances. Mid-wives were encouraged to set aside focused time with women to

J. Morrow et al. / Midwifery 29 (2013) 159–166 161

ask about the individual needs of both the woman and infant andto provide care based on this discussion.

Prior to the implementation of the postnatal changes there was acomprehensive education process that aimed to ensure that all staffunderstood the changes, the rationale for them, and how to provideand document postnatal care. This education extended into the firstfew months after the changes, with weekly sessions addressingemerging issues, in particular around documentation of care.

The multifaceted changes to postnatal care were evaluatedfrom the perspectives of both women and care providers (Forsteret al., 2011; Morrow et al., 2011). This paper reports on midwives’views and experiences of the changes to postnatal care.

Table 1Participant characteristics.

Characteristics TP1n TP2nn Overall

n % n % n %

(n¼50) (n¼50) (n¼100)

Age group20–29 years 5 10 5 10 10 10

30–39 years 10 20 7 14 17 17

40–49 years 19 38 20 40 39 39

450 years 16 32 18 36 34 34

Years working in midwiferyo1 year 1 2 1 2 2 2

1–5 years 10 20 7 14 17 17

6–10 years 6 12 5 10 11 11

11–15 years 4 8 4 8 8 8

415 years 29 58 33 66 62 62

Midwifery educationHospital programme 32 64 32 64 64 64

College/university programme 18 36 18 36 37 36

Tertiary qualifications (could tick more than one)Diploma 9 18 13 26 22 22

Degree 28 56 18 36 47 47

Graduate Diploma 20 40 15 30 35 35

Masters /PhD 0 – 0 – 0 –

None 10 20 8 16 18 18

Work fraction (n¼50) (n¼49) (n¼99)

Full time 15 30 17 35 32 32

Part time 35 70 32 65 67 68

Work place/current work area (n¼50) (n¼49) (n¼99)

Rotate through two or more clinical areas 21 42 23 47 44 44

Pregnancy clinic 1 2 3 6 4 4

Postnatal 9 18 8 16 17 17

Birth suite 7 14 6 12 13 13

Other 2 4 0 – 2 2

MGP – so no set areas 10 20 9 18 N/A

n TP1¼Time point one (6 months after the changes).nn TP2¼Time point two (2½ years after the changes).

Methods

Two methods were used in this study to explore the views ofmidwives – cross-sectional surveys and focus groups. Only theresults of the surveys are presented in this paper.

Cross-sectional surveys were undertaken at two time points:six months after the changes, in July 2008 (time point one (TP1))and two and a half years after the changes, in July 2010 (timepoint two (TP2)). All midwives employed within maternityservices, as well as midwives or nursing staff working in theSpecial Care Nursery (SCN) were sent a questionnaire at both timepoints. Casual staff were excluded.

Data collection

Questionnaires were developed specifically for the study andconsisted of a number of questions about the changes to postnatalcare. Likert-type scales required the respondent to choose from agroup of responses, i.e.: ‘strongly agree’, ‘agree’, ‘not sure’ ‘dis-agree’ or ‘strongly disagree’. Open-ended questions allowed theopportunity for further comment. The questionnaires exploredmidwives’ views regarding the safety of removing routine obser-vations; the policy of minimal disturbances to maximise rest forwomen; the perceived impact on midwives’ confidence andautonomy of practice; the time available for midwives to spendwith women; and the use of postnatal documentation. They alsoexplored midwives’ views regarding women’s satisfaction withcare after the changes and participants were asked to commenton positive and negative aspects of the changes. Demographicquestions were also included.

Piloting was undertaken with midwives who worked else-where in Victoria and who were not eligible for inclusion in thestudy. Changes were made as required and the questionnaire re-piloted, and the process repeated until the questionnaire wasconsidered clear and appropriate.

The questionnaire was attached to the pay slips of all eligiblestaff at the two time points. An attached cover letter explainedthe study and reassured staff that participation was strictlyvoluntary and that no participant could be identified. A reply-paid envelope was included for the return of the questionnaire.The initial distribution included an incentive for respondents toenter a draw for a double movie pass. Staff details to go into thedraw were able to be returned to the researchers independentlyfrom the questionnaires, so as not to jeopardise respondents’anonymity. A reminder card was attached to the pay slips twoweeks after the initial questionnaire was distributed, then a finalreminder and a second copy of the questionnaire distributed twoweeks after that. At each reminder point, staff were thanked ifthey had completed the questionnaire and asked not to completeit more than once. As the questionnaires were returned they wereassigned a unique identifier (ID), e.g. MW1001. Due to theanonymous nature of the surveys it is not known which

individual staff responded at the two time points. Changes overtime are reported as group comparisons only.

No sample size calculations were undertaken – all eligible staffwere offered the opportunity to participate.

Ethics approval to conduct the study was received from BarwonHealth and La Trobe University Human Ethics Committees.

Data analysis

Quantitative data were entered into an Access database(Microsoft, 1997) then analysed using STATA Version 9.0 (Stata,2009). Frequencies and proportions were used to describe andsummarise the data. Differences in proportions at TP1 and TP2were explored using the w2 statistic. Where scales from ‘stronglyagree’ and ‘strongly disagree’ were used they have been collapsedas ‘strongly agree’ and ‘agree’ compared with all other responses,unless otherwise stated.

Responses to open-ended questions were analysed by JM usingcontent analysis (Krippendorff, 2004). The text was scrutinisedand themes identified, grouping together responses, then eachtheme was given a title. Responses assessed as having a similarcore meaning were assigned to the same theme. Narrativeexemplars from open-ended responses were attached to eachtheme to allow colleagues within the research team (HM, DF) toassess the reliability of the coding (Lincoln and Guba, 1985).

J. Morrow et al. / Midwifery 29 (2013) 159–166162

Where direct quotes are provided in the results the respondent’sID is given.

Findings

Sixty-four per cent (50/78) of midwives responded to thesurvey at TP1 and 59% (50/84) at TP2. The majority of respondentswere aged 40 or older (73%), and 62% had worked as a midwife for15 years or more (Table 1). Almost two-thirds had completedtheir midwifery education in a hospital programme, and themajority (82%) had a tertiary qualification. Most respondentsworked part time shift work (67%) with the majority of staffrotating through various maternity areas (44%); 17% workedsolely in the postnatal area. Overall, the participant characteristicswere similar between the two time points.

Midwives’ views on how the postnatal changes would affect/did

affect women or infants

Although most midwives agreed that change to postnatal carewas needed, there was increasing uncertainty about this overtime, with 82% agreeing initially that change had been needed,and 70% agreeing two years later (p¼0.2) (Table 2). The majorityof midwives at both time points (TP1, 70%; TP2, 55%) agreed thatthe new model of postnatal care would be better for women. Mostbelieved it would allow them to provide more individualised care(TP1, 67%; TP2, 78%) and that removing routine observationswould allow them to spend more time with women (TP1, 79%;TP2, 68%). Over three quarters of the midwives believed it wassafe not to undertake routine observations on women who had avaginal birth (TP1, 79%; TP2, 76%). The majority of midwivesbelieved the ‘minimal disturbance before 9 am’ policy allowedmothers more time to rest (TP1 88%; TP2, 80%).

There was uncertainty regarding the potential impact of thechanges on women’s satisfaction with care, with less than half(TP1 45%, TP2, 49%) agreeing with the statement that ‘women’ssatisfaction will be improved’, and a similar percentage were

Table 2Views on how the changes affect women or their infants.nn

Change to postnatal care was needed

The new way of providing postnatal care will be better for women

Women’s satisfaction with postnatal care will be improved

The postnatal changes allow me to provide more individualised care

Minimal disturbance before 9 am allows mothers more time to rest

Removing routine observations allows more time to provide postnatal care

It is safe to remove postnatal observations from women who have had a vaginal bir

The changes have meant more babies are admitted to SCN

n p value based on w2 statistic, combining ‘strongly agree and agree’ compared to ann ‘Strongly agree’ and ‘agree’ and ‘disagree’ and ‘strongly disagree’ have been colla

unsure about this (TP1, 48%; TP2, 41%). There was also consider-able uncertainty regarding whether or not the new model wouldbe better for women. Overall, there was no change in midwives’views regarding the perceived impact of the changes on mothersand babies between the two surveys with one exception – at TP1,86% of the midwives disagreed with the statement ‘the changeshave meant more babies are admitted to SCN’, whereas at TP237% disagreed (86% versus 37%, po0.05), i.e. there was moreuncertainty about a possible negative impact of the changes atTP2, with 63% (24/39) being unsure. For this comparison, ‘stronglydisagree’ and ‘disagree’ were collapsed and compared to all otherresponses due to the negative direction of the question.

Midwives’ views of the effect of the postnatal changes on midwives

Midwives’ views of the changes regarding postnatal documen-tation, professional autonomy and confidence to practice wereexplored. Most respondents reported that they felt confidentproviding postnatal care without the clinical pathway (TP1, 81%;TP2, 78%), with no difference found between time points(Table 3). At TP1, approximately half of the midwives (47%)agreed that they felt more autonomous since the postnatalchanges, and this increased to 80% by TP2 (p¼0.003). Open-ended responses regarding positive aspects of the changes sup-ported this sentiment, with one midwife stating that ‘midwivesare more accountable for education and documentation, which isbeneficial for all parties’ (MW4196), and another that the changesresulted in ‘less task orientated shifts’ (MW3001). At both timepoints over half the midwives (TP1, 61%; TP2, 55%) believed thatthe new way of providing postnatal care was better for midwives.

The majority of midwives reported that they were comfortablewith leaving women undisturbed before 9 am (TP1, 64%; TP2,71%; p¼0.26) (Table 3). An open-ended question explored thisfurther and comments were generally positive, with the mostcommon response that this time was used effectively, e.g. toorganise discharge paperwork. One midwife commented that‘women seem more rested’ (MW4025) and another that ‘women

Agree Not sure Disagree

n % n % n % np

TP1 (n¼44) 36 82 4 9 4 9 0.2

TP2 (n¼40) 28 70 10 25 2 5

TP1 (n¼43) 30 70 9 21 4 9 0.17

TP2 (n¼40) 22 55 12 30 6 15

TP1 (n¼42) 19 45 20 48 3 7 0.75

TP2 (n¼39) 19 49 16 41 4 10

TP1 (n¼43) 29 67 6 14 8 19 0.28

TP2 (n¼41) 32 78 4 10 5 12

TP1 (n¼43) 38 88 4 9 1 2 0.29

TP2 (n¼40) 32 80 7 18 1 3

TP1 (n¼43) 34 79 3 7 6 14 0.26

TP2 (n¼41) 28 68 5 12 8 20

th TP1 (n¼42) 33 79 8 19 1 2 0.75

TP2 (n¼41) 31 76 4 10 6 15

TP1 (n¼43) 2 5 4 9 37 86 o0.05

TP2 (n¼39) 0 – 24 63 14 37

ll other responses.

psed into ‘agree’ and ‘disagree’, respectively.

Table 3Views on how the changes affect midwives.nn

Agree Not sure Disagree

n % n % n % np

The new way of providing postnatal care is better for midwives TP1 (n¼43) 26 61 12 28 5 12 0.61

TP2 (n¼40) 22 55 11 28 7 18

I feel more autonomous providing postnatal care since the changes TP1 (n¼43) 20 47 14 33 9 21 0.003

TP2 (n¼41) 32 80 6 15 3 8

I feel confident providing care without the care pathway TP1 (n¼42) 34 81 7 17 1 2 0.74

TP2 (n¼41) 32 78 4 10 5 12

I no longer perform routine observations on well mothers TP1 (n¼43) 40 93 0 – 3 7 0.65

TP2 (n¼41) 37 90 1 2 3 7

I find it difficult to leave women undisturbed before 9 am TP1 (n¼42) 11 26 4 10 27 64 0.26

TP2 (n¼38) 6 16 5 13 27 71

Documenting care is more difficult now TP1 (n¼42) 18 43 3 7 21 50 0.27

TP2 (n¼40) 22 55 2 5 16 40

n p value based on w2 statistic, combining ‘strongly agree and agree’ compared to all other responses.nn ‘Strongly agree’ and ‘agree’ and ‘disagree’ and ‘strongly disagree’ have been collapsed into ‘agree’ and ‘disagree’ respectively.

J. Morrow et al. / Midwifery 29 (2013) 159–166 163

are happy to sleep in as they are usually up all night’ (MW4102).Of those who made negative comments, three midwives com-mented how this change impacted on their ability to get womenready by the stipulated discharge time, e.g. ‘Difficult if you havedischarges, considering they are supposed to be discharged by1000 hrs’ (MW4001). Others felt a personal impact, with onecommenting ‘If women sleep too long workload is heavy between10–12 pm’ (MW4018) and another stating ‘It often increases mystress on a busy day’ (MW4024).

Following the removal of clinical pathways and the cessationof routine observations for women who had had a vaginal birth,around half the respondents considered the documentation wasmore difficult (TP1, 43%; TP2, 55%; p¼0.27) (Table 3). Thecommon theme was that it was difficult to know what care hadbeen provided, whereas the tick list which formed the basis of theclinical pathway provided this at a glance. One midwife com-mented that there was ‘no way of knowing EXACTLY what hasbeen discussed by the previous midwife’ (MW4113). Overall,compliance with the changes regarding routine observationswas high, with 92% reporting they no longer performed routineobservations on well women. There were no negative commentsin the responses to open-ended questions about removal ofobservations. To explore whether or not the postnatal documen-tation changes had been implemented as planned, medicalrecords were audited at two and 14 months after the postnatalchanges had been introduced. Compliance with the changes washigh, with very few routine observations recorded for healthywomen and babies following vaginal birth.

Midwives’ views on how the postnatal changes affected

communication with women (including education and information)

Midwives were asked about the effect of the postnatal changesin relation to communication with women. Despite one aim of thepostnatal changes being to increase the time midwives had tolisten to women, there was no improvement in this between timepoint one and time point two (TP1, 60%; TP2, 43%; p¼0.13)(Table 4). Less than half of the midwives agreed with thestatement ‘I routinely tell women only to use the buzzer in anemergency’ (TP1 45%, TP2 40%; p¼0.63). Due to the sensitivenature of this change, midwives at TP1 were asked an open-endedquestion about the instructions regarding the use of the call bell,and 84% (42/50) of midwives made a comment. The most

common theme was that the ward environment was more peace-ful, with less use of the call bell (n¼12); however some midwivesexpressed concerns about this change, with one midwife sayingthat ‘women feel like they are getting less help and moredemands are being put on them, e.g. making beds, seeking helpwithout using buzzers’ (MW4005).

The majority of midwives at both time points (TP1 72%, TP259%, p¼0.19) agreed that they used the NICE guidelines as aresource to give advice to mothers (Table 4). Around half of themidwives (51%) disagreed with the statement ‘It is hard toprovide all the information to women without a clinical pathway’,although there were a large number of negative comments aboutthe new documentation in the final survey, with one midwifestating ‘I think that women sometimes miss out on vital informa-tion too because there is no checklist’ (MW3014) and anothermidwife saying that the ‘caremap was nice as had info as tick box’(MW4105).

Changes by the final survey

At TP2, additional questions were asked as a result of issues thathad (anecdotally) arisen over time regarding breast feeding, post-natal documentation and women’s requests for help. Midwiveswere asked if the new policy on the use of the call bell haddecreased the use. Twenty-three per cent felt the change haddecreased call bell use, 28% were undecided and almost 50%disagreed (Table 5). Given that women were asked to use their callbell only in the event of an emergency, midwives were askedwhether or not they believed women were ‘easily able to ask forthe help that they need’. Over three quarters of midwives agreedthat women could ask for help when needed (76%). A further issuethat had arisen as a result of the removal of clinical pathways wasthe possibility that variances, for example breast-feeding issues,were not documented adequately. These anecdotal reports weresupported by the finding that over half of the midwives did notbelieve that variances were communicated well in the progressnotes (54%). Midwives were also asked whether or not they hadmore time to assist women to breast feed and 48% agreed they did.

Positive and negative aspects of the changes overall

Midwives were asked an open-ended question about what, ifany, were the positive aspects of the postnatal changes. Seventy-

Table 5Additional questions at TP2.n

Agree Not sure Disagree

n % n % n %

Since the changes I have more time to assist women to breast feed TP2 (n¼42) 20 48 16 38 6 14

Women are easily able to ask for the help that they need TP2 (n¼41) 31 76 3 7 7 17

The new buzzer system means that the buzzer is used by women less often TP2 (n¼39) 9 23 11 28 19 49

Variances to normal postnatal recovery are communicated well in the progress notes TP2 (n¼41) 11 27 8 20 22 54

n ‘Strongly agree’ and ‘agree’ and ‘disagree’ and ‘strongly disagree’ have been collapsed into ‘agree’ and ‘disagree’, respectively.

Table 4Communication with women (including education and information).nn

Agree Not sure Disagree

n % n % n % np

I have more time to listen to women since the postnatal changes/I sit and listen to women

more often since the changes

TPI (n¼42) 26 60 11 26 6 14 0.13

TP2 (n¼39) 17 43 10 26 12 31

I routinely tell women only to use the buzzer in an emergency TP1 (n¼42) 19 45 2 5 21 53 0.63

TP2 (n¼40) 16 40 3 8 21 52

I use the NICE guidelines when providing postnatal care to women TP1 (n¼43) 31 72 5 12 7 16 0.19

TP2 (n¼41) 24 59 7 17 10 24

It is hard to provide all of the information to women without a care pathway TP1 (n¼42) 13 31 7 17 22 52 0.32

TP2 (n¼41) 17 42 4 10 20 49

n p value based on w2 statistic, combining ‘strongly agree and agree’ compared to all other responses.nn ‘Strongly agree’ and ‘agree’ and ‘disagree’ and ‘strongly disagree’ have been collapsed into ‘agree’ and ‘disagree’ respectively.

J. Morrow et al. / Midwifery 29 (2013) 159–166164

six per cent (38/50) at TP1 and 72% (36/50) at TP2 responded.Comments were similar at the two time points and are presentedas combined unless otherwise specified. The most commonthemes were: woman-centred individualised care; more relaxedenvironment with increased opportunities for women to rest;flexibility of the breakfast arrangements; and a decreased needfor unnecessary tasks. At TP2, three midwives commented on theeffect on their role, saying that they were more accountable andhad increased job satisfaction.

Midwives commonly used the term ‘woman centred’ todescribe the new model of care and appreciated the individua-lised nature of the care. One midwife stated that there was ‘moreinteraction with the women because you are asking them what isimportant for them, rather than just ticking a box’ (MW4139).Some commented that they felt there were more opportunitiesfor women to rest, leading to positive outcomes, such as ‘lessteary women who haven’t had enough rest’ (MW3013). Anothermidwife commented that ‘women can ‘sleep in’ a little longernow that they can get their own breakfast’ (MW4113). There weremany positive comments on the change to breakfast arrange-ments, for example: ‘self help breakfasts are great and wellreceived by [women]’ (MW4108).

Midwives were also asked about any negative aspects of thechanges and 74% (37/50) commented at TP1 and 64% (32/50) atTP2. Again, responses were largely similar across time points soare presented together except as stated. Negative aspects of thechanges included a lack of confidence about quality of postnatalcare provision; difficulty with documentation and communica-tion; a perception of women not being ‘cared for’; and processissues related to work environment, including concern about thesafety and tidiness of the ward.

There were varied views on the changes to postnatal documen-tation, both positive and negative. One midwife suggested that‘modification of the [original] documentation may have been abetter option than removing it all together’ (MW3009). Commentsfocused on documentation of variances to ‘normal’ and how if this isnot done effectively, this poor communication could lead to carebeing ‘missed’. One midwife stated ‘some midwives are expert indocumentation according to NICE guideline[s], clearly documentingvariance[s], others are less so, therefore vital information is notcommunicated between staff’ (MW4123). Overall the comments atboth time points were that the new form of documentation wasmore time consuming, and more difficult. A small number ofmidwives at both time points were concerned that the changeddocumentation had affected the quality of the postnatal care beingprovided to women, for example ‘Due to the busy nature of apostnatal ward (i.e. elective, emergency caesarean section, dis-charges, etc.), and rotating staff I think pathways provided a check-list to make sure things were performed (it was easy to see whathad been done, what needed to be seen to). Now with the newdocumentation I think things could get missed’ (MW4034).

In both surveys some midwives raised the issue that women maynot feel cared for following the changes, for example, ‘I don’t thinkthat someone who has had a forceps/epis[iotomy]/tear should beexpected to make their own bed’ (MW4111), and ‘some women donot like getting their own breakfast’ (MW4009). Some midwivesexpressed that women appreciate having things done for them andthere was a sense that women do not ask for help if they have toactively seek it. For example ‘some women may not have theconfidence to ask for assistance’ (MW3007). Five midwives at TP1and eight at TP2 expressed concern about the untidiness of theward, in particular the kitchen and the unmade beds.

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Discussion

This study explored midwives’ views of changes to postnatalcare provision at a regional hospital in Australia where the aimwas to promote normalcy and independence for women in theimmediate postnatal period, within the in-hospital component ofpostnatal care. Interventions such as this, aimed at improvingpostnatal care provision, have rarely been undertaken, particu-larly in the context of an evaluation. Similarly, there have beenfew studies exploring the views and experiences of care providerswhen implementing new models of care.

Overall the midwives’ views of the changes to postnatal caredid not alter over time, although we did not follow individuals –respondents were non-identifiable – so we cannot comment onchanges in any individual’s views over time. Midwives weregenerally positive about the perceived effect of the changes onwomen’s experiences of hospital postnatal care, and many mid-wives suggested that these changes allowed them to moreeffectively individualise care. However they did not feel that thiswould necessarily lead to women’s satisfaction with care improv-ing and there were some concerns that women might not feel‘cared for’ with the new model of postnatal care. We cannotspeculate as to why midwives in our study did not believe thechanges would increase satisfaction, however, we exploredwomen’s views concurrently and the expectation of midwiveswas confirmed with no improvement in women’s overall rating ofpostnatal care (Forster et al., 2011; Morrow et al., 2011).

These findings are consistent with other studies of postnatalcare which have reported barriers to postnatal care provision andchallenges to providing optimal care in the postnatal setting(Cattrell et al., 2005; Forster et al., 2005). The majority ofmidwives were positive about the need for change to postnatalcare at both time points. The views of these experienced mid-wives who responded to this questionnaire (the majority havingworked in postnatal care for longer than 15 years) provide weightto the argument that midwives have concerns with postnatal carethat need to be addressed.

Following the postnatal changes at Barwon Health, midwivesreported that they were more autonomous in their provision ofpostnatal care. Midwives generally felt confident providing carewithout a tool that guided both care and documentation (theclinical pathway). They considered that this more individualisedapproach, without orientation to tasks, combined with thebroader package of changes, would result in better care forwomen, in particular around facilitating rest. A number of studieshave called for a more individualised approach to postnatal care(Cattrell et al., 2005; Schmied et al., 2008; Fenwick et al., 2010),and the midwives in this study were generally of the view thatthis outcome had been achieved.

The removal of routine postnatal observations and the changeto documentation of care were major changes to practice. Themidwives were supportive of these changes and audits ofrecords demonstrated compliance. There is a lack of clearevidence regarding the benefit or harm of performing routinepostnatal observations (Winter et al., 2001; Marchant, 2004;Rayner et al., 2008; Bick et al., 2009) and in this study midwivesdid not believe that the change involving removal of observa-tions was a risk to women’s or infants’ health. Clinical outcomesof women and their babies following the changes at BarwonHealth have been evaluated and will be reported elsewhere.Increased uncertainty about the effect of the postnatal changeson admission of infants to SCN was observed with midwivesbeing unsure if the changes would increase admissions to SCN byTP2. Open ended responses asking midwives about negativeaspects of the changes elicited no comments about any concernsabout this, or comments about issues with feeding, increased

jaundice or infections or other possible reasons as to why theyhad become unsure of the effect of the changes. Examination ofthe admission data to SCN did not reveal any increase inadmissions from the postnatal ward.

In a state-wide review of postnatal care in Victoria, only 30% ofrespondents considered clinical pathways were a useful tool thatworked well, and there were many comments made about thepoor quality of the documentation (Forster et al., 2005). In thecurrent study, most midwives reported that they felt confidentproviding postnatal care without the assistance of a clinicalpathway to guide them, and that they found the NICE evidencebased guidelines a good resource, however many midwives werenot satisfied with the new documentation. The major issues werethe communication of variances to normal progress between staffproviding postnatal care, and the extra time taken to complete thenew documentation. Further studies should explore the mostappropriate form of postnatal documentation.

The findings of this study need to be taken in context. Thestudy was undertaken in a regional hospital where there may beunique issues compared with other settings. The first survey wasconducted soon after the changes were in place. There is verylittle information about what midwives thought about the pre-vious way of providing care – apart from internal communicationthat the midwives had requested the removal of clinical path-ways. There is also very little evidence to guide change topostnatal care provision, so the concept of change might beharder to promote to the midwives working within the unit.Although the response rate of 60% was better than many otherlocal studies of midwives (Forster, 2001; Forster et al., 2003),there are midwives who did not respond and it is not possible tospeculate as to what they thought about the changes.

Conclusion and recommendations for practice

Overall, midwives were supportive of the changes to postnatalcare and over time, midwives were more likely to report feelingautonomous when providing postnatal care. They agreed thatchange was needed and were compliant with the changes,believing they were safe and would allow more time to care forwomen who in turn would receive more individualised care, andthat the changes would result in more time for women to rest.

However, midwives reported some challenges and concernsabout the changes. Although most midwives responded that theywere confident providing care without a clinical pathway, manyfelt that documentation of care was more difficult without theguidance of the pathway. They were also not confident that thechanges would necessarily translate to a measurable increase inwomen’s satisfaction with care.

It is important that care providers have access to the bestavailable evidence to guide practice, and that changes to mater-nity care provision are evaluated from the perspectives of bothwomen and care providers, given the crucial role that midwivesplay in the implementation and maintenance of the changes tocare provision. In addition, it is important to assess the impact ofchanges on the midwives themselves.

Acknowledgements

This study was funded by the Department of Human Services,Victoria. Thank you to Therese Cotter and Kim Layton for theirstrong leadership of both the postnatal changes and the evalua-tion process. Also to Jenny Kelly for her support and assistance,including distribution of the questionnaires to maternity staff.

J. Morrow et al. / Midwifery 29 (2013) 159–166166

Thanks to the midwives who took the time to participate in thestudy and to implement the changes to postnatal care.

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