Sage Journals: Discover world-class research

Abstract

The objective of this study was 1) to assess the length of stay in hospital after birth among multiparous and primiparous women, 2) to investigate relational continuity of midwifery care, 3) to investigate the validity and reliability of the home visit questionnaire, and 4) to investigate the possible positive influences of a home visit by a midwife two to six days after birth. A total of 85 postnatal women participated in the intervention group, which received home visits from a midwife, while 98 women participated in the control group, which did not receive home visits from a midwife. Of the multiparous women, 16.9% left hospital within 24 hours after birth, whereas only 4.0% of the primiparous women left hospital at this stage. No significant differences between the intervention group and the control group were evident with regard to the length of the postnatal stay. However, considering the primiparous women in the total sample, the intervention group tended to leave hospital earlier than the control group. The women who received a home visit from a midwife reported higher scores on the experience of predictability and continuity in the postnatal care than the control group. The primiparous women experienced the home visit to have a significant influence on their ability to handle the care of their newborn baby, on their mental health, and their feeling of being recognized and supported. A home visit by a midwife early after discharge from hospital seems to have a positive health-promoting influence on primiparous women's confidence and ability to handle the care of their newborn babies, and on perceived support, predictability and continuity of midwifery care.

Keywords

early discharge home visit midwifery care postnatal care relational continuity

Introduction

In Norway, the duration of postnatal stay in hospital for women with uncomplicated births has been substantially reduced.¹ Early discharge from hospital for the woman and her newborn baby is often 6–24 hours after birth and normal discharge is approximately 48 hours after birth. This reduction of the postnatal stay in hospital is judged to increase stress during the first days at home, affecting breastfeeding and the woman's ability to cope with daily activities involving the newborn baby.^2,3 As mothers have a strong desire to cope with motherhood, they tend to put aside their own basic needs, such as eating, sleeping and pain relief. Consequently, the lack of a follow up shortly after birth may affect the family's health adversely.² Many parents are caught in their feelings of incompetence because they do not know how to satisfy the baby's needs. When discharged early from hospital it is essential to get support from health professionals in order to build parental confidence.³ Professional care following birth represents an important support mechanism and a significant contribution to the long-term health and wellbeing of the mother and her baby. Accordingly, midwifery care in the postnatal period represents an essential component of health promotion and a key concern of the public health services.^4,5 It is emphasized that health promotion in the postnatal period includes professional support to enhance the family's ability to cope in their new life situation.^6,7 According to the World Health Organization, health promotion is the process of enabling people to increase control over, and to improve their health.⁸

In Norway, antenatal care is part of the primary health service, while the specialist health service is responsible for intrapartum and early postnatal care. As a result, the care is fragmented and the women encounter several different midwives and other professionals instead of continuous and trusting relationships. The Norwegian Directorate of Health⁹ has emphasized that continuity and integrated services are important for achieving the best possible outcome for the women. Several studies have shown that women who experience relational continuity of care are more likely to be satisfied with their care than women who are offered other types of care.^10–12 Relational continuity is defined as ‘an ongoing therapeutic relationship between a patient and one or more providers’.^13(p.1220) Haggerty et al. define continuity as

the degree to which a series of discrete healthcare events are experienced as coherent and connected and consistent with the patient's medical needs and personal context. Continuity of care is distinguished from other attributes of care by two core elements: care over time and the focus on individual patients.^13(p.1221)

Care during the postnatal period in Norway has until recently consisted of a home visit from a public health nurse 7–14 days after birth. National guidelines for postnatal care¹⁴ recommend home visits by a midwife in the early postnatal period. Brown et al.¹⁵ underline that there is no evidence of adverse outcomes associated with policies of early postnatal discharge of healthy mothers and term infants, as long as the midwife offers the women at least one home visit after birth. The authors emphasize that methodological limitations of included studies mean that the findings are inconclusive. Johansson et al.¹⁶ highlight that home-based postnatal care suits healthy families and that it is important to differentiate between healthy families and families in need of hospital care. Nilsson and colleagues³ underline the importance of involvement in decision making about when to be discharged. According to guidance and quality standards for postnatal care¹⁷ a documented individualized postnatal care plan should be developed in cooperation with the woman, ideally during the antenatal period or as soon as possible after birth. A postnatal home visit by a midwife serves many purposes, including health checks of the mother and baby, advice about breastfeeding and parenting as well as the identification of any additional support due to social conditions or the mother's mental health. Women highlight that it is difficult to prepare sufficiently for the postnatal period.² Consequently, it is important that midwives contribute with their knowledge and expertise, helping the woman to develop coping skills.¹⁸ Studies have shown that women are very satisfied when being offered information and guidance from the midwife during the postnatal home visit.^16,19

The present study examines the length of postnatal stay in hospital and possible health-promoting influences within the framework of a clinical collaboration project between a university hospital and a public health clinic in Mid-Norway. The objective of the project was to offer women at a public health clinic a home visit by a midwife, representing relational continuity, two to six days after childbirth. A secondary aim of the project was to reduce the length of the postnatal stay in hospital by offering midwifery care at home. This project was based on a model of relational continuity of care, where the midwife responsible for the care of the woman during pregnancy at the public health clinic also offered a home visit to the family in the postnatal period. The midwife made an appointment for the home visit the day after the woman left the hospital. At the home visit, the midwife offered individual care such as guidance in breastfeeding and baby care. The home visit also included physiological examination of the baby and the mother. The midwife offered to have a dialogue about the birth and the woman's birth experience. The home visit by the midwife did not replace the ordinary home visit by the public health nurse 7–14 days after birth.

Objectives

The objectives of this pilot study were 1) to assess the length of stay in hospital after birth among multiparous and primiparous women, 2) to investigate relational continuity of midwifery care, 3) to investigate the validity and reliability of the home visit questionnaire, and 4) to investigate the possible positive influences of a home visit by a midwife during the first days at home after birth. We expected that primiparous women would need more support from professional caregivers and therefore wish to stay longer in hospital than multiparous women. Furthermore, we presumed that when offered a home visit by a midwife, primiparous women would feel more comfortable in leaving hospital early and be better able to cope with the care of their newborn baby. Thus, knowing that they would receive a home visit by a midwife might lead to a shorter stay in hospital for primiparous women. The hypotheses tested were:

H1: Multiparous women leave hospital earlier after birth than primiparous women.

H2: When offered a home visit by a midwife shortly after birth, primiparous women will leave hospital during the first 48 hours after birth.

H3: The postnatal women in the intervention group experience more predictability and continuity of care during the postnatal period than women in the control group.

H4: A home visit by a midwife shortly after birth positively influences coping with the care of the newborn baby, feelings of support, perception of relational continuity of care and benefit mental health among primiparous women.

Methods

The participants in the intervention group were 85 out of 93 women at a public health clinic who had received a home visit by a midwife during the early postnatal period. Participants in the control group were women belonging to a similar public health clinic in the same area of the Norwegian city who had not received a postnatal home visit by a midwife. The inclusion criteria were the same for both groups: a woman who had a healthy newborn baby at term and command of the Norwegian language. The participants in the intervention group were requested to participate by the midwife during the home visit two to six days after birth, whereas participants (98 out of 100) in the control group were asked to participate by the public health nurse during the ordinary home visit 7–14 days after birth. The women were given written and verbal information about the aim of the study as well as the terms of confidentiality. They subsequently signed a written consent form. The Regional Research Ethics Committee approved the study (Ref.nb. 2014/56).

Data collection

Quantitative data were collected from the intervention and the control group from December 2013 to December 2014. Six weeks after the birth, the women in both groups answered a questionnaire at the public health clinic. In total, 183 out of 193 women (intervention group n = 85, control group n = 98) with different backgrounds completed the questionnaire, giving a response rate of 95%.

Measures

Relational continuity of care was assessed by means of the Relational Continuity Scale (RCS). This scale comprising ten items was developed based on theory and previous research in 2013. The RCS was validated among postnatal women revealing good psychometrical properties in this population.²⁰ Among sample items were ‘To what extent did you experience care as predictable?’ ‘To what extent did you experience continuity of care during pregnancy, birth and the postnatal period?’ and ‘Overall, to what extent were you satisfied with the care during pregnancy, birth and the postnatal period?’

The influence of the home visit by the midwife was assessed with help of the Home Visit Questionnaire (HVQ) developed by the authors for this study. The questionnaire was based on theory and evidence^{2,3,5,7,15,16} and contained eight items, with scores on a Likert scale from not at all (1) to very much (5). An example item was: ‘To what extent did the home visit influence your experience of coping with the care of your newborn baby?’ The women's experiences of acknowledgement and support during the home visit by the midwife was assessed by means of a one-item index framed AS1: ‘To what extent did you feel acknowledged and supported during the home visit?’ Demographic variables such as the length of the postnatal stay in hospital, age, education and parity were included in the questionnaire. Since the control group did not receive the home visit by a midwife, the home visit questionnaire was administered only to the intervention group.

This study evaluated the possible influences of the care model termed ‘relational continuity of care’.^13(p.1220) That is, we merely considered postnatal women's experiences of the home visit by the midwife, and did not assess the experiences of the ordinary visit by the public health nurse, which was not within the scope of this study. Therefore, the present data do not provide a possibility for comparing the influence of the visit by the public health nurse contra the home visit by the midwife.

Statistical analysis

The data were analysed using descriptive statistics, correlational analysis and independent t-tests for equality of means, using SPSS Version 22.0 (IBM, SPSS Inc, Chicago, IL, USA). P-values < 0.05 were considered statistically significant.²¹ The variable sense of coherence (SOC) was included in the questionnaire, but the SOC data are not part of the study presented in this article. Power calculation was based on SOC values from a recently published study examining ‘fear of birth’ during pregnancy among healthy pregnant women.²² The significance level of 0.05 was used (two-sided test), strength (1-beta) 0.80, and changes in SOC of 5 (delta), revealing a minimum of 71 participants in each group. Hence, the sizes for the intervention and control groups (n = 85 and 98) in this study conveniently exceeded the advisable threshold. Confirmatory factor analysis (CFA) was used to examine the measurement model of the HVQ. The overall model fit can be assessed statistically by the chi-square (χ²); a small χ² and a non-significant p-value corresponds to good fit,²³ the root mean square error of approximation (RMSEA), and the standardized root mean square residual (SRMR) with values below 0.05 indicating good fit, whereas values smaller than 0.08 are interpreted as acceptable.^24,25 In addition to the overall model fit, measures based on model comparison were used: the comparative fit index (CFI) and the non-normed fit index (NNFI) with an acceptable/good fit at 0.95/0.97 and above, and the normed fit index (NFI) with an acceptable/good fit at 0.90/0.95.^24,25 The frequency distribution was examined showing that both skewness and kurtosis were significant. Thus, the robust maximum likelihood (RML) estimation procedure was applied, using an asymptotic covariance matrix, stating the Satorra–Bentler scaled chi-square (χ²).²⁶ Running CFA, missing data were handled by means of the listwise procedure.

Results

Demographics

The age of the 183 women who participated in the study (intervention group n = 85, control group n = 98) ranged between 20 and 42 years. The mean age for the entire sample as well as for the intervention and control group was 31 years. The educational level of the participants ranged from primary school education to university education. All the women lived with their partners, except two. Moreover, 102 (55.7%) women were primiparous and 76 (41.5%) were multiparous (with two to four children). All of the 183 women had given birth at the same maternity unit, which is responsible for about 4000 births a year. Table 1 lists means and standard deviations for age, marital state, education, parity and duration of postnatal stay in hospital for the intervention and the control group. Table 1 also includes estimates of an independent t-test for equality of means between the intervention and the control group; no significant differences between the groups for these variables appeared. Thus, comparing the groups seemed proper. The reliability coefficients Cronbach's alpha (α) and composite reliability (ρ) for the RCS and HVQ measurement models revealed good estimates, with α = 0.766 and α = 0.86, and ρ = 0.77 and ρ = 0.88 respectively.

Table 1.

Demographic variables for the total sample and the intervention and control group. Independent t-test for comparing means between the intervention and the control group.

Groups	Total sample N = 183	Control N = 95	Intervention N = 86	Independent t-test for comparing means between the groups, df = 143
	Mean			Mean difference
Age	31 years (SD = 4.54)	31 years (SD = 5.57) 30–42 years: 56 (54.9%) 20–29 years: 36 (35.3%)	31 years (SD = 4.55) 30–42 years: 52 (44.7%) 20–29 years: 32 (27.5%)	t = 0.55, p = 0.534, mean-diff = .485 (SD = 0.873)
	Frequency
Marital state				t = –1.7, p = 0.369, mean-diff = –.153 (SD = 0.90)
Married	58 (32.0%)	32 (33.0%)	26 (30.2%)
Partner	122 (67.0%)	64 (66.0%)	58 (67.4%)
Single	2 (1.1%)	–	2 (2.3%)
Missing	1 (0.5%)	1 (1.0%)	–
Parity Primiparous	102 (55.7%)	42 (43.3%)	60 (69.8%)	t = 2.51, p = 0.397, mean-diff = 0.319 (SD = 0.127)
Multiparous	76 (41.5%)	52 (53.6%)	25 (29.0%)
Missing	5 (2.7%)	–	–
Education				t = –0.56, p = .0785 mean-diff = –0.94 (SD = 0.167)
Primary school	1 (0.5%)	1 (1.0%)	–
Secondary school	26 (14.0%)	14 (14.4%)	12 (14.0%)
University, Bachelor	67 (36.6%)	35 (36.1%)	32 (37.2%)
University, Master	80 (43.7%)	41 (42.3%)	39 (45.3%)
University, PhD	7 (3.8%)	4 (4.1%)	3 (3.5%)
Missing	2 (1.1%)
Duration of stay in hospital after birth		Mean 3.95	Mean 3.99	t = –.248, p = .309, mean-diff = –.40, (SD = .160)
12 hours	3 (1.6%)	3 (3.1%)	–
24 hours	14 (7.7%)	3 (3.1%)	11 (12.9%)
48 hours	48 (26.4%)	29 (29.9%)	19 (22.4%)
60 hours	38 (20.8%)	23 (23.7%)	15 (17.6%)
≥60 hours	79 (43.2%)	39 (40.2%)	40 (47.1%)
Missing	–	–	1 (1.2%)

Note: SD = standard deviation; df = degrees of freedom.

Length of stay in hospital after birth

This study's first hypothesis (H1) asserted that multiparous women would leave hospital earlier after birth than primiparous women. With regard to the length of the postnatal stay, 13 of the multiparous women (16.9%) left hospital within 24 hours after birth. On the other hand, only four of the primiparous women (4.0%) left hospital this early, as shown in Table 2. The number of women leaving hospital within 48 hours after birth was 35 in the multiparous group and 10 in the primiparous category. No significant differences between the intervention group and the control group were evident regarding the length of stay (Table 1).

Table 2.

Descriptive statistics, crosstabulation. Length of stay in hospital after birth reported by the control group and the intervention group, sorted by parity (primiparous and multiparous).

Length of stay in hospital after birth	Groups		Total
Length of stay in hospital after birth	Control	Intervention	Total
Multiparous women
≤24 hours	6 (11.5%)	7 (28%)	13 (16.9%)
≤48 hours	22 (42.3%)	13 (52%)	35 (45.5%)
>48 hours	24 (46.2%)	5 (20%)	29 (37.7%)
Total	52 (100%)	25 (100%)	77 (100%)
Primiparous women
≤24 hours	0 (0%)	4 (6.8%)	4 (4.0%)
≤48 hours	4 (9.5%)	6 (10.2%)	10 (9.9%)
>48 hours	38 (90.5%)	49 (83.1%)	87 (86.1%)
Total	42 (100%)	59 (100%)	101 (100%)

Primiparous women in the intervention and control groups – differences

The second hypotheses (H2) stated that when offered a home visit shortly after birth, the primiparous women would also tend to leave hospital early, meaning within the first 48 hours after birth. Examining the possible differences between the primiparous and the multiparous women in each of the groups revealed a difference: the primiparous women in the intervention group tended to leave hospital earlier compared to the primiparous women in the control group (Table 3).

Table 3.

Primiparous women's length of postnatal stay in hospital by the intervention and the control group.

	Group statistics					t-test for equality of means
Variable	Group	N	Mean	SD	sd.e.	t-test df = 99	sig	Mean diff (st.diff.error)
Length of stay in hospital	Control	42	4.57	.668	.103	1.186	0.034*	.199 (.167)
Length of stay in hospital	Intervention	59	4.37	.927	.121	1.186	0.034*	.199 (.167)

Note: *significant at the 0.05 level. SD = standard deviation, sd.e. = Standard Error Mean, df = degrees of freedom, st.diff.error = Standard Error Difference.

Relational continuity of care

We proposed (H3) that women receiving a home visit by a midwife would report higher scores on RCS than the control group. An independent t-test for equality of means between the groups (Table 4) revealed significant differences for two out of nine of the RCS items: RCS4 (experiencing the care to be predictable, p = 0.038) and RCS9 (experience of continuity of care, p = 0.010). In addition, women in the intervention group scored higher on feeling cared for during pregnancy as well as during the postnatal period; however, this was not significant and might be a finding by chance.

Table 4.

Relational Continuity Scale (RCS); means, standard deviation and independent t-test for equality of means between the control group and the intervention group.

	Mean (SD)	Mean (SD)	t-test for equality of means
Items	Control (90)	Intervention (84)	t (df = 172)	sig	Mean diff	SD
RCS1 To what extent did you feel cared for during pregnancy?	4.22 (.633)	4.45 (.625)	−2.750	0.095	−0.263	0.096
RCS2 To what extent did you feel cared for during birth?	4.05 (.993)	3.96 (.893)	0.564	0.447	0.080	0.142
RCS3 To what extent did you fell cared for during the postnatal period?	4.09 (.834)	4.29 (.749)	−1.988	0.057	−0.219	0.110
RCS4 To what extent did you experience the care as predictable?	3.83 (.837)	4.01 (.744)	−1.751	0.038*	−0.212	0.121
RCS5 To what extent did you feel prepared to go home from hospital?	4.27 (.797)	3.99 (.906)	1.896	0.652	0.245	0.129
RCS6 To what extent did you feel confident in motherhood when leaving the hospital?	4.46 (.647)	4.25 (.754)	1.915	0.951	0.206	0.107
RCS7 To what extent did you feel confident with care for the baby when leaving the hospital?	4.71 (.503)	4.56 (.609)	1.551	0.360	0.129	0.083
RCS9 To what extent did you experience continuity of care during pregnancy, birth and the postnatal period?	3.66 (.834)	4.01 (.790)	−2.648	0.010*	−0.356	0.135
RCS10 Overall, to what extend were you satisfied with the care during pregnancy, birth and the postnatal period?	4.14 (.720)	4.39 (.638)	−2.588	0.593	−0.271	0.105
RCS_MEAN_1	37.43 (4.11)	37.87 (4.15)	−0.701	0.667	−0.436	0.621
RCS_MEAN_2	37.07 (4.23)	37.67 (4.51)	−0.663	0.050	−0.635	0.913

Note: *significant at the 0.05 level. Listwise N: Control group N = 90, Intervention group N = 84. Item RCS8 revealed non-significant correlations with the other scale items, probably due to a bad wording. Therefore, this item was excluded from the analysis. RCS_MEAN_1 = mean score for RCS scale in the whole sample. RCS_MEAN_2 = mean score for RCS scale among primiparous women.

The Home Visit Questionnaire (HVQ) – validity and reliability

The measurement model of the HVQ including eight items was evaluated by means of confirmative factor analysis. Factor loadings (λ) between 0.94–0.47 with only one λ < 0.5 for item HVQ3, and squared multiple correlations (R²) between 0.22–0.89 were exposed, as well as acceptable fit indices: χ² = 38.98, p = 0.0067, χ²/df = 1.95, RMSEA = 0.11, 90% confidence interval RMSEA = 0.054–0.15, NFFI = 0.95, CFI = 0.97, SRMR = 0.069. Good values for the reliability coefficients Cronbach's alpha (α = .86) and composite reliability (ρ_c = .88) were shown. Thus, the validity and reliability of the HVQ in this study seemed acceptable. Figure 1 portrays the HVQ measurement model. Table 5 shows estimates for the HVQ measurement model as well as the theoretical model tested.

Figure 1.

Measurement model for the Home Visit Questionnaire (HVQ).

Table 5.

Home Visit Questionnaire (HVQ): items, means, standard deviation (SD), confirmative factor analysis (CFA) including factor loadings (λ), squared multiple correlations (R²), fit indices for the measurement model,^a and reliability coefficients (α, ρ_c).

		Descriptives		CFA
Item	Item wording	Mean	SD	λ	R ²
HVQ1	To what extent did the home visit influence your ability to express feelings about your birth experience?	2.90	1.063	0.53	0.28
HVQ2	To what extent did the home visit influence your experience of relational continuity and predictability in the midwifery care?	3.69	0.976	0.54	0.29
HVQ3	To what extent did the home visit influence your experience of coping with breastfeeding?	3.06	1.131	0.47	0.22
HVQ4	To what extent did the home visit influence your experience of coping with the new family situation?	2.97	1.011	0.83	0.69
HVQ5	To what extent did the home visit influence your experience of coping with the care of your newborn baby?	3.12	1.067	0.88	0.78
HVQ6	To what extent did the home visit influence your experience of feeling confident in motherhood?	2.98	1.062	0.94	0.89
HVQ7	To what extent did the home visit positively influence your mental health?	2.80	1.094	0.70	0.49
HVQ8	To what extent did the home visit positively influence your physical health?	2.52	1.003	0.58	0.34
Reliability coefficient Cronbach's alpha α		.86
Reliability coefficient Composite reliability ρ_c				.88

fit indices for the measurement model: χ² = 38.98, p = 0.0067, χ²/df = 1.95, RMSEA = 0.11, 90% confidence interval RMSEA = 0.054–0.15, NFFI = 0.95, CFI = 0.97, SRMR = 0.069. Listwise N = 178.

The intervention group: Positive influences of the home visit

Hypothesis four (H4) stated that the home visit by a midwife shortly after birth would positively influence coping with the care of the newborn baby, feelings of support, perception of relational continuity of care and benefit the mental health among primiparous women. Table 6 lists the results that compare mean scores between the primiparous and the multiparous women participating in the intervention group. A statistical comparison between the multiparous and the primiparous women in the intervention group revealed a significant influence of home visits on the primiparous women; at the scale level (Table 4) p = 0.050, which is the limit for significance. At the item level, the home visit significantly influenced their experience of relational continuity and predictability in midwifery care (p = 0.044), their ability to care for their newborn baby (p = 0.018), their mental health (p = 0.030) and their feeling of being acknowledged and supported (p = 0.016).

Table 6.

Intervention group: perceived influence of the home visit (HVQ) and experience of support (SA1) among the primiparous women compared to the multiparous women.

Items	t-test for equality of means
	t	df	Sig. (2-tailed)	Mean Difference	Std. Error Difference	95% Confidence interval of the difference
	t	df	Sig. (2-tailed)	Mean Difference	Std. Error Difference	Lower	Upper
HVQ1 To what extent did the home visit influence your ability to express feelings about your birth experience?	−0.814	83	.418	−.207	0.254	−0.712	.299
HVQ2 To what extent did the home visit influence your experience of relational continuity and predictability in the midwifery care?	−2.050	82	.044*	−.470	0.230	−0.928	−.013
HVQ3 To what extent did the home visit influence your experience of coping with breastfeeding?	−1.002	83	.319	−.270	0.269	−0.806	.266
HVQ4 To what extent did the home visit influence your experience of coping with the new family situation?	−1.201	83	.233	−.290	0.241	−0.770	.190
HVQ5 To what extent did the home visit influence your experience of coping with the care of your newborn baby?	−2.410	83	.018*	−.590	0.240	−1.072	−.101
HVQ6 To what extent did the home visit influence your experience of feeling confident in motherhood?	−1.377	83	.172	−.347	0.252	−0.847	.154
HVQ7 To what extent did the home visit positively influence your mental health?	−2.210	83	.030*	−.570	0.260	−1.076	−.058
HVQ8 To what extent did the home visit positively influence your physical health?	−0.221	83	.826	−.053	0.241	−0.533	.426
SA1 To what extent did you feel acknowledged and supported during the home visit?	−2.469	83	.016*	−.373	0.151	−0.674	−.073

Note: Intervention group: primiparous women (listwise N = 59) and multiparous women (listwise N = 25). SA1 represents the one-item assessment of support. *significant at the 0.05 level.

Discussion

This study assessed the length of stay in hospital after birth among multiparous and primiparous women, as well as the possible health-promoting influences of a postnatal home visit by a midwife shortly after birth. Four hypotheses were tested (H1–H4), all of which were supported by the empirical data in this study. The present findings showed that the multiparous women left hospital earlier than the primiparous women (H1). As the multiparous women have one child or more at home, their motivation for an early discharge from hospital might be high. Moreover, among the multi-parous women the transition to becoming a mother is part of their previous experience. First-time mothers often experience insecurity and anxiety in understanding and handling the baby the first days after birth. They often need professional support for breastfeeding and baby care.²

The second hypothesis (H2) explored the differences between the multiparous and the primiparous women who had all received a home visit shortly after birth. The study shows that in cases where the primiparous women were offered a home visit, they left hospital within 48 hours after giving birth. The fact that the women in the intervention group were aware that they would receive a home visit from a midwife shortly after arriving back home might explain this finding. Possibly, this assurance made the primiparous women feel more confident about leaving hospital early. Even though many women experience the first period after birth as overwhelming, they tend to consider early discharge from the maternity ward as safe when they know they can expect a home visit by the midwife within a few days.²⁷ The women want to be able to influence the timing of their discharge from hospital, regardless of whether this is early or after a few extra days.²⁸ In line with the National guidelines for postnatal care,¹⁴ the time spent in hospital should be adjusted according to the individual needs of the woman and the newborn baby. An early discharge should be conditioned by properly organized services at the home place and available support from the woman's partner and social network. McLachlan et al.²⁹ highlight a need for greater flexibility in facilitating early postnatal discharge, as a fixed length of stay may undermine the requirements of individualized care. In a similar vein, Fenwick and colleagues¹⁹ stress that attempts to reduce the length of the postnatal stay without providing community support is inappropriate, outdated and unsustainable. They emphasize that implementation of new models of care that value relational interaction between the woman and the midwife as well as the right approach is important.

The primiparous women in the intervention group experienced that the home visit significantly influenced their mental health, and their feeling of being supported (H4). This is notable, given that support is found to help prevent postpartum depression.³⁰ The mothers want midwives to provide more care and support,³¹ though it is a challenge for the midwives in the specialist healthcare services to satisfy both the physical and emotional needs due to the short period of postnatal care in hospitals and the limited resources of the midwife profession.³² Studies show that women perceive the quality of the midwifery care during the early postpartum period to be better at home than in hospital. This is due to the hospital environment where the midwives are busy and difficult to contact. As a result, the midwives do not give priority to the emotional aspects of care and the women often perceive the advice they receive as inconsistent.^16,19 The women in a study by Dahlberg and co-workers²⁸ claimed that the midwife tended to focus on the emotional aspect of becoming parents during the home visit. According to them, the midwives did not exclusively devote themselves to the needs of the baby, but also seemed interested in the wellbeing of the woman and her partner. Women may need professional support to take care of themselves in the first week of the postnatal period.^2,18 Barimani and colleagues³¹ found that mothers want more attention paid to their own needs and that physical and emotional support is strongly appreciated. Razurel et al.³³ emphasize that emotional and social support is more essential than practical knowledge in the early postnatal period. Whether the women encounter challenges or experience the postnatal period as completely normal seems to have an insignificant effect on the need for support and recognition from the midwife. When the midwife is able to support the women in their decisions and understanding of the situation, it seems to promote a feeling of safety, confidence and coping.

The primiparous women in the intervention group also experienced the home visit by the midwife to significantly influence their ability to care for the newborn baby (H4). This finding indicates a health-promoting influence of the home visit on primiparous women, as coping with early parenting enhances empowerment.¹¹ Individualized available support focused on developing and recognizing the parent's experiences of taking care of their baby increases their sense of parental confidence.^3,7,34,35 The physical presence and availability of professional support help to alleviate concerns about the safety and wellbeing of the newborn baby, especially for first-time mothers.³⁶ Guidance in relation to breastfeeding is important, in particular when the breastfeeding is in an early stage. This guidance along with advice about how to fulfill the baby's needs may contribute to a sense of coping.² Furthermore, unfulfilled needs tend to increase the use of medical services.³⁷ When the women feel safe about the conditions affecting the baby, they might become more aware about themselves and their own basic needs, like eating, sleeping and treating sore breasts.²

In the present study, the women who received a home visit by a midwife reported higher scores on predictability and continuity in the midwifery care (H3) than the control group (Table 4). The primiparous women in the intervention group experienced the home visit to have a strong influence on the perceived relational continuity of their maternity care (H4). This is supported by Dahlberg and colleagues²⁸ and Aaserud and co-workers³⁵ who found that women who were visited by a midwife they had met before experienced the visit as more significant, especially with regard to the emotional aspect and the processing of the birth experience. Continuity in the relationship increases the woman's confidence in the midwife's expertise, advice and guidance. At the same time, the midwife helps her to believe in her own resources.¹¹ Studies reveal that relational continuity of midwifery care often helps the woman and her partner to gain attention and be respected. This type of care is based on a health-promoting approach and is associated with a positive birth experience.^11,38 In our study, we found that the primiparous women in the intervention group who received relational continuity in the midwifery care, experienced that the home visit significantly influenced their feeling of being acknowledged and supported as well as influenced their ability to care for the newborn baby (Table 6).

In Norway, maternity care is fragmented, marked by a number of staff members interacting with vulnerable women.³⁹ Conflicting opinions, information and practices may result in negative perceptions about the care.^40,41 Relational continuity of care can improve both the effectiveness of healthcare and its efficiency, with fewer staff handovers and more consistency in the care provided. It may further reduce the demand for additional services and the number of hospital admissions, while increasing patient satisfaction.^42,43 Relational continuity of care responds to the women's need to have a relationship with one person or team, and receive consistent information.^40,41 This model of care is seen as a vital condition for offering high-quality healthcare.^{11,19,31,38,44,45} The National guidelines for postnatal care¹⁴ recommend a home visit by a midwife within the first couple of days after discharge from the hospital. Both the midwife and the public health nurse have a health-promoting approach, but still the focus is different. Midwives have expertise in women's health, pregnancy, childbirth and the postpartum period.⁴⁶ At the home visit, she is focused on the woman and her baby's health and wellbeing. The midwife may also contribute to boost the confidence of the woman in her new situation, helping her to develop skills as a mother. On the other hand, the expertise of public health nurses is focused on children, adolescents and families,⁴⁷ with an emphasis on the baby's health and development. Public health nurses may contribute to positive bonding and good family relationships. Stronger interdisciplinary collaboration and familiarity with different areas of competence will lead to a more efficient use of resources and skills and ensure that follow-up programs during the early postnatal period to a greater extent respond to the unique needs of each woman, baby and family.⁴⁸ The childbearing period is open to salutogenic interventions with an emphasis on health-promoting strategies, such as mobilization of the resources required to prepare for the changes following birth. Midwifery should have a stronger focus on the fact that individual needs and the coping experience of the woman are important when empowering a new family.^11,16,27,49

Limitations

The small sample size of the intervention group (N = 85) and the control group (N = 98) represent a limitation of this study. The same applies to the high number of primiparous women in the intervention group (n = 59) compared to those in the control group (n = 42) (Table 3). An equal distribution of primiparous women in the two groups could have exposed significant differences between the groups. With regard to sample size, the power calculation revealed a desired sample size of N = 71 for the two groups. Subsequently, the sample size in this study should be sufficient. However, a larger sample would significantly increase the statistical accuracy of the tests. Moreover, the HVQ developed for this study has not been used and validated previously. Regarding the RCS, item 8 was excluded due to some misspecification. Item RCS8 includes to what extent the participants felt prepared to be a parent. However, item RCS6 includes confidence in motherhood, which is a wording very close to item RCS8.

Conclusions

No significant differences between the intervention group and control group regarding the length of the postnatal stay in hospital were discovered. Still, there was a significant difference between the primiparous and the multiparous women in the total sample, insofar as the primiparous women in the intervention group left hospital earlier than the primiparous women in the control group. The women who received a home visit by a midwife reported higher scores on predictability and continuity in the midwifery care than the control group. Furthermore, the primiparous women experienced a significant influence of the home visit on their ability to cope with the care for the newborn baby, as well as on their mental health and feeling of being acknowledged and supported. They also reported a perceived relational continuity of midwifery care. Accordingly, a postnatal home visit could have a health-promoting influence on both mental health and the ability to cope, resulting in a shorter postnatal stay in hospital to the benefit of the woman, the newborn baby and society. A model of midwifery relational continuity of care, including a postnatal home visit shortly after birth, should be further developed and studied with the help of larger samples.

Footnotes

Acknowledgements

The authors would like to thank the women who participated in this study.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

The authors declare that there is no conflict of interest.

References

Ministry of Health and Care Services. White paper 12. ‘A happy event’: continuous pregnancy, birth and postnatal care, Oslo: Ministry of Health and Care Services, 2009.

Hjälmhult

Lomborg

. Managing the first period at home vith a newborn: a grounded theory study of mothers' experiences. Scand J Caring Sci 2012; 26: 654–662.

Nilsson

Danbjørg

Aagaard

et al.

Parental experiences of early postnatal discharge: a meta-synthesis. Midwifery 2015; 31: 926–934.

Warwick

Foreword. In: Byrom

Edwards

Bick

(eds). Essential midwifery practice: postnatal care, Oxford: Wiley-Blackwell, 2010.

Schmied

. Postnatal care: current issues and future challenges. Midwifery 2014; 30: 571–574.

Ministry of Health and Care Services. White paper 47. The interaction reform, Oslo: Ministry of Health and Care Services, 2009.

Persson

Fridlund

Kvist

et al.

Mothers' sense of security in the first postnatal week: interview study. J Adv Nurs 2011; 67: 105–116.

World Health Organization (WHO). The Ottawa Charter for health promotion. First International Conference on Health Promotion, Ottawa, 21 November 1986.

Norwegian Directorate of Health. Safe maternity services: quality requirements for maternity care, Oslo: Norwegian Directorate of Health, 2010.

10.

Huber

Sandall

. A qualitative exploration of the creation of calm in a continuity of carer model of maternity care in London. Midwifery 2009; 25: 613–621.

11.

Aune

Dahlberg

Ingebrigtsen

. Parents' experiences of midwifery students providing continuity of care. Midwifery 2012; 28: 432–438.

12.

Sandall

Soltani

Gates

et al.

Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Rev 2016; 4: CD004667.

13.

Haggerty

Reid

Freeman

et al.

Continuity of care: a multidisciplinary review. BMJ 2003; 327: 1219–1221.

14.

Norwegian Directorate of Health. National guidelines for postnatal care: ‘new life and safe postnatal care for the family’, Oslo: Norwegian Directorate of Health, 2014.

15.

Brown

Small

Argus

et al.

Early postnatal discharge from hospital for healthy mothers and term infants. Cochrane Database Syst Rev 2009; 3: CD002958.

16.

Johansson

Aarts

Darj

. First-time parents' experiences of home-based postnatal care in Sweden. Ups J Med Sci 2010; 115: 131–137.

17.

National Institute for Health and Care Excellence (NICE). NICE guidelines CG37. Postnatal care up to 8 weeks after birth, http://www.nice.org.uk/guidance/cg37/chapter/1-recommendations (2006, accessed 4 March 2016).

18.

Fahey

Shenassa

. Understanding and meeting the needs of women in the postpartum period: the perinatal maternal health promotion model. J Midwifery Womens Health 2013; 58: 613–621.

19.

Fenwick

Butt

Dhaliwal

et al.

Western Australian women's perceptions of the style and quality of midwifery postnatal care in hospital and at home. Women Birth 2010; 23: 10–21.

20.

Aune

Dahlberg

Backe

et al.

Comparing standard maternity care with team midwifery care provided by student midwives – a pilot study: women's experiences and clinical outcomes. Vård i Norden 2013; 33: 14–19.

21.

Norušis

. SPSS statistics 17.0: guide to data analysis, Upper Saddle River, NJ: Prentice Hall, 2008.

22.

Takegata

Haruna

Matsuzaki

et al.

Antenatal fear of childbirth and sense of coherence among healthy pregnant women in Japan: a cross-sectional study. Arch Womens Ment Health 2014; 17: 403–409.

23.

Jøreskog

Sørbom

. LISREL 8: structural equation modeling with the SIMPLIS command language, Chicago, IL: Scientific Software International, 1995.

24.

Bentler

. Fit indices in covariance structure modeling: sensitivity to underparametrized model misspecification. Psychological Methods 1998; 3: 424–453.

25.

Schermelleh-Engel

Moosbrugger

Muller

. Evaluating the fit of structural equation models: tests of significance and descriptive goodness-of-fit measures. Method Psychol Res 2003; 8: 23–74.

26.

Satorra

Bentler

Corrections to test statistics and standard errors in covariance structure analysis. In: von Eye

Clogg

(eds). Latent variable analysis: applications to developmental research, Thousand Oaks, CA: Sage, 1994, pp. 399–419.

27.

Askelsdottir

Lam-de Jonge

Edman

et al.

Home care after early discharge: impact on healthy mothers and newborns. Midwifery 2013; 29: 927–934.

28.

Dahlberg

Haugan

Aune

. Home visit by midwives in the early postnatal period: women's experiences. Midwifery 2016; 39: 57–62.

29.

McLachlan

Forster

Yelland

et al.

Is the organisation and structure of hospital postnatal care a barrier to quality care? Findings from a state-wide review in Victoria, Australia. Midwifery 2008; 24: 358–370.

30.

Dennis

. Psychosocial and psychological interventions for prevention of postnatal depression: systematic review. BMJ 2005; 331: 15.

31.

Barimani

Oxelmark

Johansson

et al.

Support and continuity during the first 2 weeks postpartum. Scand J Caring Sci 2015; 29: 409–417.

32.

Fink

. Early hospital discharge in maternal and newborn care. J Obstet Gynecol and Neonatal Nurs 2011; 40: 149–156.

33.

Razurel

Bruchon-Schweitzer

Dupanloup

et al.

Stressful events, social support and coping strategies of primiparous women during the postpartum period: a qualitative study. Midwifery 2011; 27: 237–242.

34.

Hildingsson

Sandin-Bojö

A-K

. ‘What is could indeed be better’: Swedish women's perceptions of early postnatal care. Midwifery 2011; 27: 737–744.

35.

Aaserud

Tveiten

Gjerlaug

. Hjemmebesøk av jordmor i tidlig barseltid [Home visit by a midwife in the early postnatal period]. Sykepleien Forskning 2016. DOI: 10.4220/Sykepleienf.2016.59215.

36.

Forster

McLachlan

Rayner

et al.

The early postnatal period: exploring women's views, expectations and experiences of care using focus groups in Victoria, Australia. BMC Pregnancy Childbirth 2008; 8: 27.

37.

Kronborg

Vaeth

Kristensen

. The effect of early postpartum home visits by health visitors: a natural experiment. Public Health Nurs 2012; 29: 289–301.

38.

Dahlberg

Aune

. The woman's birth experience: the effect of interpersonal relationships and continuity of care. Midwifery 2013; 29: 407–415.

39.

Sandall

Hatem

Daven

et al.

Discussions of findings from a Cochrane review of midwife-led versus other models of care for childbearing women: continuity, normality and safety. Midwifery 2009; 25: 8–13.

40.

Jenkins

Ford

Morris

et al.

Women's expectations and experiences of maternity care in NSW: what women highlight as most important. Women Birth 2014; 27: 214–219.

41.

Jenkins

Ford

Todd

et al.

Women's views about maternity care: how do women conceptualise the process of continuity?

Midwifery 2015; 31: 25–30.

42.

Cabana

Jee

. Does continuity of care improve patient outcomes? J Fam Pract 2004; 53: 974–980.

43.

Dreiher

Comaneshter

Rosenbluth

et al.

The association between continuity of care in the community and health outcomes: a population-based study. Isr J Health Policy Res 2012; 1: 21.

44.

Hunter

Berg

Lundgren

et al.

Relationships: the hidden threads in the tapestry of maternity care. Midwifery 2008; 24: 132–137.

45.

Sandall

Devane

Soltani

et al.

Improving quality and safety in maternity care: the contribution of midwife-led care. J Midwifery Womens Health 2010; 55: 255–261.

46.

Curriculum for Midwifery Education. Department of Nursing Science, Midwifery Education, Faculty of Health and Social Science, Norwegian University of Science and Technology, Norway, 2014.

47.

Curriculum for Public Health Nurse Education. Department of Nursing Science, Public Health Nurse Education, Faculty of Health and Social Science, Norwegian University of Science and Technology, Norway, 2014.

48.

Aune

Olufsen

. ‘From fragmented to interdisciplinary understanding of integrated antenatal and postnatal care’: an interprofessional project between public health nursing students and midwifery students. Midwifery 2014; 30: 353–358.

49.

Ferguson

Davis

Browne

et al.

Sense of coherence and childbearing: a scoping review of the literature. Int J Childbirth 2014; 4: 134–150.

Health-promoting influences among Norwegian women following early postnatal home visit by a midwife

Abstract

Keywords

Introduction

Objectives

Methods

Data collection

Measures

Statistical analysis

Results

Demographics

Length of stay in hospital after birth

Primiparous women in the intervention and control groups – differences

Relational continuity of care

The Home Visit Questionnaire (HVQ) – validity and reliability

The intervention group: Positive influences of the home visit

Discussion

Limitations

Conclusions

Footnotes

Acknowledgements

Funding

Conflict of interest

References