Being connected: Exploring the needs of mothers during the postnatal period in Queensland,Australia

Abstract

This project explored the needs of mothers beyond the immediate postnatal period in Queensland, Australia, for the development of improved models of care. Data were collected through group and individual interviews. A qualitative methodology using thematic analysis captured the experience of 58 participants. Four key themes were generated: Caring for self, Being connected, Getting direction and Having options. Being connected with care providers and peers was highly valued by participants as was having a sense of direction. Having a relationship with a carer who knew them personally throughout pregnancy and postnatal care avoided retelling stories and facilitated information sharing. Relationship-based care enabled mothers to better meet their personal needs necessary to fulfil the parenting role. Yet, many points of disconnect were identified including inconsistencies in information and gaps in care. These findings demonstrate a range of unmet needs, situated within a lack of relational continuity. Maternity and child health professionals, service managers and policy makers must reorient systems by listening, acknowledging and keeping the voice of mothers at the centre of care.

Introduction

Evidence is compelling of the benefit for women and their babies who receive continuity of care from a known midwife across pregnancy, birth and to at least 6 weeks postnatal (Sandall et al., 2016). Yet, little evidence is available to inform best practice models beyond this period despite growing recognition of the first 1,000 days (conception to age two) as pivotal to lifelong health and wellbeing (Moore et al., 2017). This paper reports the results of consumer consultation to understand postnatal needs of mothers living in a variety of contexts and divergent geographical areas of Queensland, Australia. The objective was to use this local information to inform improvement in models of care (MoCs) and support maternal and child health care across the first 1,000 days of life.

Background

There are 16 Hospital and Health Services in the state of Queensland spanning metropolitan, regional, and rural and remote areas. Public maternity and child health services vary from community based to tertiary level care and are free of charge (Queensland Health 2015). Variation also occurs across the state in respect to access and timeliness of child health care. Key to developing MoCs was to understand the needs of women in the postnatal period. Peer-reviewed literature specific to the Australian context published between 2010 and 2020 was explored to understand existing knowledge as a basis to inform this work.

It was found that women are often overwhelmed in the early weeks after the birth. Mothers’ decisions are impeded by lack of preparation and understanding of breastfeeding challenges, lack of support and information from professionals, and conflicting information especially around breastfeeding (Sheehan et al., 2010; Clark et al., 2015). Decision-making is made more difficult as mothers balance personal needs with wanting to do the best for their baby (Sheehan et al., 2010). Services are often not well coordinated (Clark et al., 2015). Women identified newborn and family drop-in services as useful to fill gaps in care between hospital and community services with breastfeeding support being the most frequently cited reason for attendance (Rowe et al., 2013). Open-access clinics were particularly popular due to timeliness and ease of access (Rowe et al., 2013). In the early weeks this was for baby weight monitoring, but over time parents became more interested in talking with a child health nurse (CHN) about general aspects of infant care and child development (Kearney and Fulbrook, 2014). Also for reassurance about normal behaviours and having time to ‘practice’ skills such as feeding helped mothers to connect with their babies and gain confidence (Rowe et al., 2013).

Women have been shown to visit a number of postnatal care providers for information and support, with General Practitioners (GPs) favoured for immunisation and medical concerns and CHNs for parenting advice and well child checks (Rossiter et al., 2019b). Many parents, however, report not visiting services because they do not see a need, have limited interest in the information provided, do not know about services or because services are inaccessible (Morawska et al., 2018; Rossiter et al., 2019b). Parents also report conflicting advice from CHNs and GPs (Kearney and Fulbrook, 2014).

Accessible services where women do not feel rushed or judged are associated with positive experiences of care and feeling included in decision-making (Corr et al., 2015). Developing a sense of trust, not being rushed or judged and providers being accessible are all important to parents, as is receiving up to date information (Rossiter et al., 2019a, 2019b). Having a known and trusted professional who is supportive is important; someone who knows them and their story (Rossiter et al., 2019a, 2019b). Women report a preference for personalised care rather than seeing different care providers (Corr et al., 2015). Further, women want to be respected and supported to make their own decisions about infant care and to receive positive feedback on their parenting (Corr et al., 2015; Eronen et al., 2011).

In the perinatal period a significant number of parents experience emotional health challenges with feelings of being disconnected and isolated (Highet et al., 2014). As a result, women report difficulties with making decisions, feel disorganised and lack confidence which impact on the ability to seek help (Highet et al., 2014). Women report losing a sense of self where the needs of infants are prioritised (Highet et al., 2014). Other factors contribute to emotional health issues such as emotional changes, relationship issues, sleep deprivation, feeding and settling issues, and social and geographical isolation (Biggs et al., 2019). Also they are more likely to open up about their own physical and emotional needs with a GP when asked directly and if there is empathy, understanding and a relationship of trust (Hartley et al., 2012). On the other hand, access to appointments, time in consultations, feeling rushed and having children present all impede exploring a mother’s personal needs (Hartley et al., 2012).

Unclear service pathways and conflicting messages from health professionals as well as difficulties accessing services, social isolation and loneliness, lack of postnatal support and lack of family support challenge postnatal migrant women in Australia (Renzaho and Oldroyd, 2014; Shafiei et al., 2015). Women born overseas and who speak a language other than English in the home are less likely to report involvement in decision-making about their baby, to know about care options and are less likely to feel safe in the postnatal period (Hennegan et al., 2015). Migrant women often do not talk of their distress or their own health with a GP or CHN and some do not understand that nurses are an appropriate source of assistance for themselves (Shafiei et al., 2015). Being rushed or not being asked about their own emotional needs are common reasons women do not seek help with emotional concerns (Shafiei et al., 2015).

Women who birth in private birthing facilities report concerns about post-discharge care more often than those who birth in public funded care arrangements (Zadoroznyj et al., 2015). Lack of information about how to care for their babies, inconsistent information about breastfeeding, lack of support and self-care, as well as inadequate knowledge about available services all lead to gaps in care (Zadoroznyj et al., 2015; Woodward et al., 2016). Woodward et al. (2016) found the highest level of satisfaction with post-birth care was reported by women who had employed a private midwife for care through pregnancy, birth and postnatal and had opted for a homebirth. Women here revealed how important it was to have a connection with a midwife who understood their personal needs. Women who used pharmacy or baby shop services also valued psychosocial aspects of care although expressed concerns with nurses practicing in open areas of pharmacies including near baby goods sections (Woodward et al., 2016). Mothers reported it was difficult to build a sustained relationship with specific nurses although they found social support (mother’s groups) of great benefit (Woodward et al., 2016).

Having a consistent nurse over time as occurs with sustained CHN home visiting programs benefited women’s emotional health and ability to care for themselves, including enhanced relationships with others and greater childcare confidence (Zapart et al., 2016). A bond with the nurse allowed some women to feel calmer, more relaxed, less stressed and worried, able to cope and to respond to their baby’s needs more effectively (Zapart et al., 2016). Continuity of midwifery carer models that provide clinical, psychosocial and educational care are strongly linked with more positive outcomes for women in the early days and weeks after birth (Lewis et al., 2016a). Here, a relationship with a known midwife alleviates feelings of gaps in care that can cause women to experience isolation at a very vulnerable time (Lewis et al., 2016a). When women have opportunities to explore experiences including an opportunity to reflect on birth events through the relational approach of a known midwife across the full continuum of care, emotional distress can be addressed and alleviated (Fenwick et al., 2013). However, few women can access this care (Homer, 2016).

A recently reported program in Australia explored experiences of women participating in a group psycho-educational programme extending across pregnancy and early postpartum (Buultjens et al., 2019). In this program women developed relationships with other women before the birth which removed many barriers to receiving support and reduced feelings of isolation (Buultjens et al., 2019). This group of women emphasised relational continuity and valued information from midwives and CHNs who they knew over time. Having access to expertise and resources in one place was also more convenient, enhanced understanding of options for care and promoted support of one another as they gained confidence in their maternal role (Buultjens et al., 2019).

Overall, available evidence demonstrates a range of continuing unmet needs and dearth of literature on the needs of mothers residing in remote areas. There is clear evidence mothers favour care where they feel personally supported, cared for, and can develop connections.

Aim

The aim of this project was to explore the postnatal needs of mothers living in a variety of urban, regional and remote areas throughout Queensland. Understanding needs would fill a gap in current knowledge about desired care beyond the immediate postnatal period. This knowledge would be used to inform the development of MoCs that would improve and support maternal, child and family primary health care.

Method

An exploratory, interpretive design was followed. The project was reviewed and approved by the Children’s Health Queensland Hospital and Health Service Human Research Ethics Committee Chair as meeting the national guidelines as a quality assurance activity. All ethical guidelines for human research were followed. Individual interviews and focus groups were conducted by the first author. Focus groups were relevant because they involve a non-directive style that encourages discussion to elicit a variety of viewpoints (Kvale and Brinkmann, 2009). Additionally, individual interviews were used to gain a more in-depth understanding of specific needs.

Setting and recruitment

Data were obtained through a convenience sample at one metropolitan, one regional and one remote/rural site. Mothers were opportunistically recruited through existing early parenting groups and local networks at each site. The population of interest were mothers who had children under 12 months of age. The aim was to invite established groups to be inclusive of all mothers. Mothers were also invited to participate in an individual interview. Information was distributed to participants prior to each consultation by local health staff.

Data collection

The same interviewer conducted all six consultations and was not known to participants. Privacy was discussed as well as respect for all contributions in groups. A short discussion with all participants outlined how information would be used to develop new MoCs. Participants were informed sessions would be audiotaped and transcribed and would not contain any identifying information for reporting purposes. The facilitator began each interview with a broad opening question such as ’When you have a baby and you come home, what are the sorts of things that you need?’ ‘What do you need now?’ Exploring and clarifying questions were used to tap into points of interest that developed such as ‘In terms of accessing that support, how easy was that?’ and ‘So it was important that they knew you?’

Data analysis

Audio recordings were transcribed by an independent supplier and checked for accuracy by the interviewer. Thematic analysis was conducted to identify, analyse and report themes within data incorporating principles outlined by Braun and Clarke (2006). Transcripts were read through by project members to become familiar with data. Highlighting text in transcripts and developing ideas through memo writing allowed patterns of meaning and issues of potential interest to be identified. Data were organised using NVivo (QSR International) Version 11. Discussion between authors and engagement with literature extended analysis.

Findings

A total of 58 consumers participated in the consultations (four focus groups (FG) and two individual interviews). Apart from one father and one grandmother who were present in the focus groups, all participants were mothers. One individual interview was with an Aboriginal and Torres Strait Islander woman who had to leave her remote home to give birth in a regional centre. A health worker known to her was also present. A further individual interview captured experiences of a mother from a rural community whose child had complex needs following a pregnancy complication. The nurse known to this mother also attended. Four key themes (Caring for self, Being connected, Getting direction and Having options) were generated from data and are elaborated below.

Caring for self

Participants described how moving from pregnancy, where care was centred on the woman, to focus on the baby after birth left a gap in maternal care. Mothers identified how important it was to have their personal needs acknowledged. This was more than being asked, it involved having someone who knew them, knew their stories, who would have a genuine concern and probe sensitively. This relationship provided the backdrop for conversations about emotional needs. This woman stressed:

We had a Child Health check last Tuesday. Even the nurse then sat down and said “And how are you? Are you okay?” Yeah, so that’s really important for me that that still happens. I think that if that’s something that could continue in terms of support and that it’s not just for baby but baby and mum. (Louise)

Participants described how developing peer relationships through parent groups or social media were other ways to explore self-care. The CHN or midwife continued to be important here, with the GP also mentioned. Yet, some described feeling rushed with GP care which left little time to share their experiences or to discuss their own needs as highlighted here:

I was talking to her about my birth, and … it was pretty traumatic and everything. She said, well what happened? I said, oh such-and-such. She goes, oh, it was just such-and-such? I'm like, no. I’ve been crying about this for weeks, it’s not just such-and-such. (FG1)

Being connected

Self-care was linked closely to having connections which was a frequent topic of discussion. Some participants reported practical help from partners and family in early days was important, but this soon grew to connecting with other mothers and their babies. This allowed them to share information, gain support, grow confidence and be connected to their communities. Connections with experienced peers were especially valued. Real stories provided encouragement and were useful to store information for future reference. Peer support groups facilitated conversations in a different way to individual interactions. They allowed a space to listen, reflect and normalise experiences as described here:

I think listening to other people talk, and you realise oh yes, that happened to me too…and then brought up a conversation that you probably wouldn’t think to have if it was one-on-one. Then you know you’re not the only one. You know you’re not alone. (FG1)

Connections with CHNs and midwives were highly valued to gain evidence-based information from a trusted health professional. Knowing someone who would understand their experience and who knew their personal stories enabled them to open-up and speak about concerns and to feel safe to ask ‘silly questions’. Continuity of the same professional was valued because the connection meant the personal journey was known which avoided retelling stories as this mother explained:

It wasn’t a new person all of a sudden. I found it was really nice. You don’t need to explain yourself every time …they go “Oh so has this changed since last time we spoke?” Oh yes you know what I am talking about. (FG2)

Experienced staff were those who could pick up on signs that extra care was needed. Lack of connection with care providers was reported by mothers across different sites, although it was amplified when women were required to birth away from home or had complex needs. Connections were especially important to have someone who would advocate for them and know care options.

Getting direction

Just as connections were sometimes lacking, lack of direction experienced by participants occurred when in-time support and information was lacking. Incomplete information, conflicting advice, and gaps between services, particularly between public and private services were contributing factors. Lack of in-time information impacted decision-making although participants described how confidence grew. This was described as moving from a position of ‘doing things right’, to ‘doing what was right for us’. At times more directed information was thought best to support decisions but at other times different sources and opinions enabled them to consider options. Although mothers learnt to integrate and ‘filter out’ what they needed to make their own decisions over time, it was most difficult in the very early days after birth as illustrated by this first-time mother:

There was just so many different ways of doing things, that they would tell you what to do, and you think, oh well I’ll do it that way then. Then someone else would come in and say, no, do it this way. It is like, oh, what do I do? I don't know, it’s my first time. (FG1)

Following birth, participants described how gaps in services contributed to a lack of direction because no plan appeared to exist. Limited access to the infant’s personal health record book in hospital, that explained recommended follow up visits, was also raised as an issue. For some mothers transitioning to child health services relied on opportunistic information as this woman explained:

I never knew about any of this until the midwife talked about the weigh-in centre. Then the weigh-in centre told me about the group that we go to on Wednesday. Then the Wednesday group told me about this class today. So, I never really found out straight away…(FG1)

Other participants reported ‘service overload’ where several care providers were involved but left gaps in care requiring mothers to find their own way as described here:

Because we went privately, so we then had a follow-up with our GP, a follow-up with the obstetrician, and a follow-up with the child health nurse publicly. So, it was almost a bit of service overload…I think about eight weeks everyone dropped off unless you seek out the support. (FG4)

Disconnects between general medical practice, private obstetric and public maternity systems and later between public maternity and child health systems left mothers feeling vulnerable, especially when complex care needs existed. Lack of information exchange between services was highlighted by this woman:

Never once was I ever referred to a Queensland Health hospital ever, so when we went to (town) they had never heard of me, they didn't know anything about my history. (Louise)

Having options

At times gaps in systems were managed by midwives and CHNs who contacted mothers to explain care options. At other times mothers received mixed messages about which services they could use. Home visits from midwives and CHNs were highly valued, especially in early days after birth when women struggled to get out. Drop-in services were also highly valued because being on time for appointments was difficult with a new baby especially if there were other children. Participants discussed how facilitated group sessions were appreciated because they could access opportunistic information and peer support, with a CHN or midwife both available. Parents could attend group discussions but also schedule individual appointments with the CHN or midwife. In this way families could tailor their care to individual needs as described here:

…so that’s really good because you can have a chat with people, but also there’s somebody there if you need to ask questions. (FG3)

Access to drop-in clinics appeared to vary across the state with some services available for early weeks after birth, whilst at other sites for several months. In one remote site, services took a different approach to access where health workers would reach out to mothers and invite them to attend local clinics when health checks were due. Furthermore, when midwives and CHNs worked together in the same space, care seemed more organised. This woman commented:

They send out invitations like with the workers there to go around and pick (mothers and babies) up. (Rebecca)

In general, participants reported a lack of knowledge about service options and eligibility. Child health services were seen by some as only for when concerns arose as this woman mentioned:

I haven’t felt the need to keep coming. Depending, I guess, on your situation… like, they referred me to the sleep school, and that was good. Then after that, I felt like everything was going okay, so I haven’t needed it. (FG1)

Many did not discriminate between roles of midwives and CHNs and many did not realise the range of child health services available.

Discussion

Advice from mothers in this project provided contextual relevance and highlighted areas for the developing MoC in Queensland. Findings revealed barriers for maternal and child health providers to meet the holistic needs of mothers with no current model providing the relational care desired.

Continuity of a known carer was voiced as important. This alleviated re-telling stories and facilitated discussion of experiences and concerns, that were important to find direction and form connections for confident parenting. Other studies confirm how midwives, CHNs and women alike report negative experiences when stories have to be repeated throughout care (Psaila et al., 2014; Lewis et al., 2016b; Rossiter et al., 2019a) and how it is more difficult to bring up and discuss emotional issues without a known carer (Eronen et al., 2011). Having adequate time for disclosure of concerns and to open conversations is pivotal but a connection with a known carer, as shown in this work, facilitates this process further. A trusted, known carer was often the first port of call for mothers and it was within this relationship that there was less fear of asking questions.

Having health professionals enquire after personal needs of mothers was consistently highlighted in the consultations. Personal adjustment issues, balancing work and care, managing relationships, and changes to sense of self are important concerns in early parenting years (Rossiter et al., 2019a). Mothers identified that when conversations around self-care were actively raised, they could talk about concerns more readily which allowed them to be more available as a parent. Other studies support how women value a focus on their personal needs separate, and additional to, those of the baby and that feeling cared for, through a consistent relationship with a care provider is vital (Fenwick et al., 2013). Furthermore, enquiry, listening skills, communication style, including access to, and time in consultations can impact on disclosure and perceived support after birth (Rossiter et al., 2019a; Hartley et al., 2012; Corr et al., 2015). In this project some mothers did have a GP that they knew well enough to provide for their personal needs; most often where prior healthcare needs existed.

Drop-in services, early home visits after birth and attending parent groups were all identified by mothers as highly valued, as confirmed in other studies (Rossiter et al., 2019a; Kearney and Fulbrook, 2014; Rowe et al., 2013; Woodward et al., 2016). Drop-in services were valued for opportunistic information, however some living in rural areas found access difficult. Whilst drop-in services in the towns were valued, a suggestion for connections via ‘virtual groups’ was proffered.

How systems of care are structured has implications for continuity of carer models. Where CHNs and midwives are moved around the workplace and are required to provide care in teams this breaks connections that women most desire (Corr et al., 2015; McLelland et al., 2015). Services in Australia are often not structured to support relationship-based care and tensions exist between professions around who is best placed to provide care to women and children (Schmied, 2014). In this project, mothers identified they would have liked connection across the continuum however were not aware of midwifery continuity of carer programs or due to high demand were unable to access them. Midwifery care generally ends at 6 weeks postnatal and maternal and child health continuity programs are not always available. Sustained home visiting models in Australia where ongoing care is provided by one supportive CHN to age two have been shown to be highly valued by women (Zapart et al., 2016). A focus of this model is for a CHN to connect with a woman during pregnancy and reconnect postnatal. Whilst this does not cover maternity or labour care, early connections provide an opportunity to develop a supportive consistent relationship, particularly for women experiencing socio-economic disadvantage (Kemp et al., 2011, 2012).

Consistent, reliable, and evidence-based information was highly valued by mothers and is well supported in other studies (Rossiter et al., 2019a; Kearney and Fulbrook, 2014; Zadoroznyj et al., 2015). Mothers were aware when they received inconsistent advice although, over time they found other ways to access information and make their own decisions. For example to discuss information with partners, family, health professionals and with other parents in groups and through online forums. Mothers described how they ‘filtered out’ what they needed to make their own decisions, a process also evident in other studies (Rossiter et al., 2019a).

Participants suggested antenatal parent groups could facilitate early connections with midwives and CHNs but also with peers. The idea of ‘doing the journey together’ functioned to connect mothers through relationships. Group-based perinatal education can potentially improve health outcomes, provide information and social support for mothers and ease transition to parenthood by removing some of the barriers to accessing support and services after birth (Buultjens et al., 2019). Furthermore, the diverse needs identified and discussed in groups create a greater awareness of options and information that can increase confidence in decision-making to fulfil the maternal role (Buultjens et al., 2019; Rising et al., 2004). When groups extend from antenatal through to after birth they can be more beneficial than standard maternal and child health groups because they alleviate breaks in care, and allow relationships formed prior to birth to be renewed more easily, reduce isolation, and provide a safe place to share experiences (Buultjens et al., 2019). Whilst many mothers described how they found their way to services after birth it was not always clear to them how this would occur. The need for clearer service pathways has been identified in previous studies (Kearney and Fulbrook, 2014; Woodward et al., 2016; Rowe et al., 2013).

Gaps identified by mothers between private and public systems confirm what has been identified in previous studies (Woodward et al., 2016; Zadoroznyj et al., 2015). Lack of connectivity and direction was heightened where pregnancy and child complications were present, leaving mothers uninformed and care feeling unsafe.

Limitations

This project was conducted to elicit needs of mothers in Queensland where there are unique challenges including the remote and rural spread of health services and discrete areas of need and as such the findings may not be generalisable. Whilst a variety of viewpoints about the needs of mothers was sought there were limited mothers from Aboriginal and Torres Strait Islander and culturally and linguistically diverse backgrounds, or young mothers. Additionally, the needs of mothers who were not accessing services were not available which limits the findings.

Implications for practice

A range of unmet maternal needs in the postnatal period required to improve MoCs across the first 1,000 days of life have been highlighted. It is evident that MoC must shift focus to address relational continuity and lack of connections that persist in current systems. Consultation in a variety of contexts is imperative if MoC are developed to meet the unique needs of mothers and ensure safe and quality care.

Conclusion

This work placed the voices of mothers within the context of Australian studies published over the last decade emphasising a range of unmet maternal needs. Many of these needs are situated within a lack of relational continuity. The implications of unmet needs include difficulties making decisions, lack of access to services, limited knowledge of care options, discontinuities in care, social isolation, lack of mothers’ personal needs being met and lack of emotional support. The need for professional and peer connections highlights the importance of developing systems that focus on building capacity and confidence for mothers that enable them to grow and learn across the continuum from early pregnancy through to parenting. A social and salutogenic model of health built into MoC to wrap around families from the earliest opportunity would represent a significant opportunity to improve care. For real change to occur it is important that professionals, service managers and policy makers engage in reorienting systems and, most importantly, that the voice of mothers be paramount in the design of care systems.