Bridging the gap in the chain of care for expectant and new mothers

University dissertation from Stockholm : Karolinska Institutet, Dept of Neurobiology, Care Sciences and Society

Abstract: Background and aim: Professional support from midwives and child health care nurses is important in the early postpartum period. The dramatic decrease in the length of postpartum hospital stays that has occurred in western countries requires that attention be paid to the continuity of care for expectant and new mothers. The aim of this thesis was to explore professionals’ and mothers’ perception of support and continuity in the chain of care for expectant and new mothers. Material and methods: Both qualitative (study I and II) and quantitative (study III and IV) research methods were selected. Studies I and II used a grounded theory methodology approach. In study I, thirty-two midwives and child health care nurses were interviewed in five focus groups and two individual interviews. In study II, multiple data sources were used that comprised structured interviews with midwives and child healthcare nurses (n=20), as well as mothers (n=21), participant observation, and written material. Studies III and IV were based on the same cohort of mothers, using a cross-sectional questionnaire survey focusing on mothers’ satisfaction with support from antenatal care (AC), postpartum care (PC) and child health care (CHC) during the first two weeks after childbirth (n=546). In study III, descriptive and logistic regression analyses were performed. In study IV, a mixed method design was used by logistic regression and content analysis. Results: A theoretical model was created that explained why collaboration between midwives and child health care nurses is not realized even when there are visions of such collaboration. Barriers to linkage included lack of professional benefit and link perspective, while facilitators were chain of care perspective and professional benefit. Three main strategies to achieve linkage in the chain of care were identified, termed: transfer, establishing and maintaining a relationship, and adjustment. These strategies for continuity formed the basis of the core category: professional joint action. In all three strategies for continuity, midwives and child health care nurses worked together. In addition, mothers benefited from the professional joint actions and recognized continuity of care when strategies for continuity were implemented. Mothers’ perceived satisfaction with professional support during the first two weeks after childbirth showed that fifty-three percent of the mothers rated the support received as sufficient or more than sufficient, 29.7% as neither sufficient nor insufficient, and 17.7% as insufficient or completely insufficient. As many as 17% of the mothers in the study population visited hospital emergency departments during the first two weeks after childbirth, as a result of problems related to delivery, breastfeeding, or infant health. A higher frequency of such emergency visits was associated with poor perception of professional support, low sense of coherence, and delivery complications. A large discrepancy showed up between AC, PC and CHC. Mothers were satisfied with support from health care nurses at CHC but they missed follow-up contacts from midwives at AC and PC. Nearly 40% of the mothers commented on insufficient support. They lacked continuity and found support regarding their physical and emotional health insufficient. Having fewer than 37 gestation weeks was associated with reduced satisfaction with both AC and CHC. Mothers making emergency visits during the two first weeks were more likely to be dissatisfied with support from PC. Conclusions. All links in the chain of care are important to support mothers during the first two weeks after childbirth; nevertheless, the results indicate a lack of continuity in postpartum care. Continuity needs to be improved in order to raise the quality of care for new mothers by increasing the linkage in the chain of care for expectant and new parents.

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