Description of the condition
The postpartum period can be a special, though often challenging, time for a mother and her new family as significant physical, psychological and social changes occur (Shaw 2006). Health professional contact in the first month following birth may contribute to a smoother transition and help prevent and manage infant and maternal complications.
While serious postpartum medical problems such as haemorrhage, thromboembolic disease, infection and eclampsia are well described, there are many medical and behavioural issues during the postpartum period that are under recognised, under reported (Schmied 2009) and hence, inappropriately managed (Schmied 2009; Tunçalp 2012).
Postpartum morbidities occur commonly throughout the world (Cheng 2008). For mothers these include tiredness (31% to 59%) (Brown 1998; Glazener 1995; Lagro 2003; Miller 2011; Saurel-Cubizolles 2000; Schytt 2005; Woolhouse 2012), backache (24% to 55%) (Brown 1998; Glazener 1995; Lagro 2003; Miller 2011; Saurel-Cubizolles 2000; Woolhouse 2012), depression (19% to 34%) (Brown 1998; Glazener 1995; Miller 2011; Saurel-Cubizolles 2000), headaches (18% to 47%) (Glazener 1995; Lagro 2003; Saurel-Cubizolles 2000; Schytt 2005; Woolhouse 2012), perineal pain (10.7% to 34.7%) (Brown 1998; Miller 2011; Saurel-Cubizolles 2000; Schytt 2005), urinary incontinence (18% to 30%) (Brown 1998; Glazener 1995; Miller 2011; Thompson 2002; Woolhouse 2012), bowel problems (19% to 45%) (Brown 1998; Thompson 2002; Miller 2011), faecal incontinence (4.5% to 8%) (Brown 2000; Woolhouse 2012) and constipation (10% to 27%) (Glazener 1995; Lagro 2003; Saurel-Cubizolles 2000; Schytt 2005; Woolhouse 2012). Problems such as postpartum anxiety, prolonged bleeding and urinary tract infections are also reported (Keppler 1995; Marchant 2002; Miller 2011).
Ongoing postpartum depression is associated with poorer maternal physical health (Brown 2000). Compromised maternal physical health is associated with a reduction in the mother's capacity to work, look after children or undertake household tasks (Webb 2008). Poorer physical and mental health is also associated with increased infant crying and sleep problems (Bayer 2007), which ultimately has a negative impact on the health, development and well-being of children when aged three (Kahn 2002).
Breastfeeding issues including breast engorgement, sore nipples and mastitis are common, especially in the first few weeks following birth (Hauck 2011). Women are more likely to not breastfeed or stop breastfeeding early if they have ongoing physical and mental health issues (Amir 2010; Dennis 2009; Forster 2006). Similarly, women are more likely to wean if their infant is unsettled, they think they do not have enough milk, they have painful nipples or breast problems (Hauck 2011). Limited or no breastfeeding increases infant morbidity and mortality in the short and long term and increases maternal risk for breast and ovarian cancer, Type-2 diabetes and cardiovascular disease (Horta 2007; Ip 2007; Stuebe 2010).
In terms of infant morbidity, the most common problems following hospital discharge include jaundice (32.6%), feeding difficulty (16.1%), weight loss (13.9%) and nappy rash (10%) (Bennett 1998). In addition, infant crying (Hiscock 2006) and sleep disturbances are common causes of concern for parents (Bayer 2007).
These medium- and long-term consequences of inadequate management of physical and mental health issues in the immediate postpartum period are often not recognised, leading to suboptimal health of the mother/infant dyad and additional expenditure for overburdened health systems (Bartick 2010; Renfrew 2012a).
Postpartum care in the community is becoming increasingly important as post-birth hospital stays have reduced substantially over the past 20 years (Cuncarr 2011; Dana 2003; Goulet 2007; Lancaster 1994; Li 2012) due to fiscal constraints (Dana 2003; Gagnon 2002) and the reduction in the number of postpartum beds within hospitals (McLachlan 2009). Postpartum follow-up provides a suitable opportunity to identify and manage these maternal and infant health issues and provide information so that mothers are better prepared for potential problems that may be encountered after childbirth (Schytt 2005). The Cochrane Systematic Review by Brown et. al. (Brown 2009) found no evidence that early hospital discharge had a detrimental effect on maternal and infant health or breastfeeding rates. However, all studies included in the review provided post-discharge nursing or midwifery support. Nevertheless, it appears that different models of post-discharge care result in differing hospital readmission rates (Goulet 2007), maternal satisfaction (Madden 2004) and changes in the use of primary care services (Mandl 2000). Overall, appropriate care in the weeks following childbirth has the potential to contribute to the health and well-being of the new mother and her family.
Description of the intervention
The main goals of postpartum care in the community are to: provide a safety net to identify important postpartum conditions (e.g. jaundice, puerperal infection, depression); to uncover and manage other physical and/or mental health problems of the mother and/or infant; to build maternal confidence in parenting skills and to support breastfeeding, thereby increase family well-being and satisfaction (Wiegers 2006).
Community postpartum interventions aimed to improve maternal and infant outcomes such as breastfeeding rates, maternal morbidities including postpartum depression and infant morbidity, include telephone or other telehealth contact, home visiting by a nurse or midwife, a visit by the mother to a community or hospital-based clinic, or a combination of these.
At present there is great variation between existing models of postpartum care in different countries and within the same country. In the United States of America, the American Academy of Pediatrics recommends a visit to a paediatrician within 72 hours of hospital discharge if discharged within 48 hours of birth (AAP 2010), but there is limited home visiting (Mandl 2000). In other countries, home visiting is more common. For example, the NICE (National Institute for Health and Clinical Excellence) guidelines, designed for use by those who work in the National Health Service (NHS) in England and Wales, propose a care pathway to optimise maternal and infant health and infant feeding (Demott 2006). They suggest information and care be provided within 24 hours of birth, between days two and seven and between weeks two and eight. Midwifery care is provided up to 28 days post-delivery, followed by health visitor care (Bull 2004). In the Netherlands, women receive up to five or six home visits within the first 10-12 days following early discharge or a home birth (Wiegers 2006) and in Denmark, most women are also offered a home visit within the first 10-14 days (Kronborg 2012). In contrast, in Switzerland postpartum care in the mother's home is provided by self-employed midwives who visit up to 50% of postpartum women (Kurth 2010). Within Australia, there are no consistent recommendations between States, with the provision of almost universal contact by home visiting midwives and then child health nurses occurring in some areas (Biro 2012; Victorian Department of Health 2012), while in others less than 50% of women receive a home visit, some receive a telephone call only and others have no contact with a health professional at all during the first 10 days postdischarge (Miller 2011). There are also programs that target specific populations (Brodribb 2012; Kemp 2010) without an organised, overarching system or recommendation.
As yet, it is not clear whether health professional contact in the early postpartum period is beneficial, and if it is, what form this contact should take. It may be, that for some women, health professional contact has a detrimental effect due to incorrect information or advice being given or a reduction in the mother's self-efficacy for breastfeeding and other parenting skills. While it would be impossible to compare the effects of 'usual care' across jurisdictions, it is possible to assess the impact of health professional contact interventions in addition to 'usual care'. Although it is recognised that in many places a routine visit is usually scheduled at the end of the postpartum period (i.e. around six weeks), this review is concerned with the impact of earlier contact (e.g. up to and including four weeks).
How the intervention might work
Ideally, timely and appropriate postpartum care should increase breastfeeding continuation rates, identify maternal depression, improve maternal satisfaction with care and confidence in parenting, and decrease utilisation of health services such as general practice, obstetric or paediatric consultations, emergency department visits and readmissions to hospital. Early postpartum health professional contact, including appropriate discussion, may increase a mother’s awareness of what is ‘normal’ and what is not, encourage earlier reporting of maternal and infant problems and facilitate adequate management and treatment (Schytt 2005).
A Cochrane review by Renfrew 2012 found that breastfeeding support interventions had a positive effect on breastfeeding continuation and exclusive breastfeeding. Subgroup analysis found lay support appeared more beneficial than professional support, that postpartum interventions had similar outcomes to interventions that included both an antenatal and postpartum component and that face-to-face interventions were more effective than telephone or mixed interventions. Another recent Cochrane review on the schedules for home visits in the early postpartum period (Yonemoto 2013) found inconsistent results on their effect on maternal and neonatal mortality/morbidity, maternal satisfaction and neonatal immunisation. A recent Cochrane review (Lavender 2013) assessed telephone contact in the antenatal and/or postpartum period and found that there was not enough evidence to support changes in care, although there appeared to be a benefit for some outcomes.
One English study found that an intervention with extended midwifery contact (to three months) improved mothers' mental health status, but not their physical health, compared with usual care by general practitioners (MacArthur 2002).There is also evidence that screening by health professionals at well-child visits increases detection of maternal depression (Sheeder 2009). Treating postpartum depression is also likely to improve other facets such as sleep quality and child development (Dorheim 2009). Additonal visits to medical practitioners have also been assessed. In one study there was no improvement in maternal and child health or breastfeeding rates (Gunn 1998), while in another there was improvement in breastfeeding rates, at least in the short term (Labarere 2005).
Dana and Wambach (Dana 2003) found that women had high satisfaction levels with nurse home visits after early postpartum discharge. The significant factors contributing to this were friendliness and concern, technical skill, infant care teaching and addressing individual needs (Dana 2003). A Western Australian study reported that mothers were particularly happy with practical advice, assistance with baby care and immediate physical recovery that were provided via midwifery care at home (Fenwick 2010). In addition to contributing to maternal satisfaction, quality postpartum care may also improve maternal confidence. In a qualitative study by Forster 2008, women reported feeling more confident in caring for their new infant when health professionals were physically available (both in hospital and at home) to answer concerns.
Why it is important to do this review
Postpartum maternal and infant health issues are common and are a major cause of concern for many new families. Yet there is little consistency in the type, frequency, timing, location and availability of health professional contact women receive in the postpartum period both within and between countries (Schmied 2010; Wiegers 2006). In addition, there are differences in duration and content of the contact and qualifications of the health professional provider (Kemp 2010; Wiegers 2006). Evidence to indicate that one regimen is more effective than others in supporting families and preventing maternal/infant morbidity in the postnatal period is lacking (Bull 2004). However, in many areas governments and health services are spending increasing amounts of money to ensure health professional contact to postpartum women, regardless of need or length of hospital stay. In some circumstances the decision to provide a service is based on political will and health service logistics rather than on maternal and infant need or evidence of improved outcomes. Comparing different interventions for community postpartum care, will provide an evidence-based approach to the most efficacious use of resources for all mothers. This information will be particularly useful for policy makers deciding how healthcare dollars should be spent (Bull 2004; Cooke 1999). In order to avoid overlapping with the recent Lavender 2013 review, our review will not include telephone contact but will look broadly at all other forms of health professional postpartum support and their effect on a wide range of outcomes.