Improving care for new mothers with postnatal morbidity in Ireland

Contrary to the perception that a woman will be healed both in body and mind during the postnatal period and reverting to their pre-pregnancy state (Way, 2012), few women come through birth completely unscathed. Some women's pregnancy and childbirth are associated with suffering and ill health (Singh and Newburn, 2000; World Health Organization (WHO), 2008; Halperin et al, 2015). For these women, life becomes a challenge, with their pregnancy and birthing experience having a profound negative effect on their physical and mental wellbeing (Singh and Newburn, 2000; WHO, 2008). Therefore, the importance of high-quality postnatal care cannot be underestimated, as it may have a lasting effect on a mother's short- and long-term health (Royal College of Midwives (RCM), 2014). Maternal morbidity is a wide-ranging concept that refers to any ‘physical or mental illness, or disability directly related to pregnancy and/or childbirth, resulting in acute or chronic ill health for women’ (Hardee et al, 2012). Morbidities need to be assessed, treated and managed effectively to significantly enhance the quality of women's lives (Webb et al, 2008; Prick et al, 2015). More specifically, in a recent National Institute for Health and Care Excellence (NICE, 2021) guideline on postnatal perineal pain, it was suggested ‘that poor perineal pain management can lead to long term physical, psychological, and psychosexual difficulties’. The review committee also acknowledged the important benefits of healthcare professionals with suitable expertise addressing perineum problems as early as possible with women, to give reassurance and effective healthcare.

A culture change is required to bring to the forefront the importance of specific, safe quality care to meet the individual needs of each postnatal mother. One aspect that needs to be changed is the introduction of a specific morbidity clinic dedicated to all women, nationally and globally, who suffer from maternal morbidity.

Postnatal maternal morbidity clinics are a relatively new concept in many countries. In Ireland, a novel clinic explicitly dedicated to assessing and treating non-life-threatening maternal morbidities was developed in 2013. The clinical midwife manager of the outpatient department set up this clinic at the National Maternity Hospital, a busy stand-alone maternity hospital. The manager established an ad-hoc approach to postnatal care within the organisation, with no specific clinician assuming responsibility for assessing, managing and following up on new mothers' postnatal morbidities. Following their discharge home, if women had any clinical issues or concerns in the postnatal period, they would attend the hospital's emergency department or their general practitioner to assess and manage their morbidities. An audit of the hospitals' emergency department highlighted that 25% of attendees were postnatal women. The lack of formal postnatal care offered within the hospital reflected Wray's (2012) worldwide findings that postnatal care receives the least focus from professionals.

The postnatal maternal morbidity clinic was set up and operated by the midwife manager and a consultant obstetrician at the National Maternity Hospital. This is compliant with the NICE (2013) guidelines that recommend that postnatal services should be expanded to meet the needs of mothers who suffer complications following childbirth. Attendance to the site's postnatal morbidity clinic has significantly risen since its inception (122 attendees in 2013 to 720 in 2020) (National Maternity Hospital, 2020). The National Maternity Strategy 2016–2026 (Department of Health (DoH), 2016) recommends providing opportunities for service user feedback and engagement in improving maternity services, listening to women's voices about what can be improved. In view of this recommendation and that no literature on women's experiences of attending a postnatal morbidity clinic in Ireland exist, it was deemed imperative to undertake this research. The study aimed to capture women's experiences of attending the postnatal morbidity clinic and document their recommendations for improvements to the service.

Methods

As part of a larger mixed-methods study design, a cross-sectional survey was completed. The survey instrument was developed and validated from two questionnaires: the Satisfaction with Outpatient Survey (Keegan and McGee, 2003) and the Consultation and Relational Empathy (Mercer et al, 2004), which were modified with the authors' permission to include demographic information, questions about waiting times and spaces for free-text comments. Survey validation was conducted using a series of steps to validate the two standard questionnaires for applicability to Irish maternity healthcare. This included consultation with an expert panel; a number of cognitive interviews were completed by four service users, one member of the professional development department, one staff midwife in the outpatient department, one student midwife with no knowledge of the clinic and one midwifery clinical skills facilitator. The survey was designed to be self-completed by women who had attended and been discharged by the morbidity clinic.

Sampling and recruitment

Convenience sampling was used to recruit participants. All women discharged from the clinic over 6 months (October 2018–March 2019) were invited to participate, a total of 176 women. All women who attended the clinic in the 6-month timeframe were contacted via post and invited to complete an enclosed survey. A detailed information leaflet accompanied the survey. Additionally, a link to an online version of the survey (using the same content) was included in the information leaflet.

Data collection and analysis

The survey was composed of 46 items. Women were asked about previous medical and obstetric history and their rating of different aspects of their care at the clinic. Space was available for free-text comments about any improvements that could be made to the clinic and any other comments the respondents would like to add. Descriptive statistics were undertaken on the nominal and categorical data using the Statistical Package for Social Sciences (version 24). Following this, inferential statistics were undertaken on ordinal data. Qualitative data received from the open-ended questions were analysed thematically to complement the quantitative data received.

Ethical considerations

Ethical approval was granted by the Research Ethics Committee of the National Maternity Hospital. The survey was anonymous, both the written and the online version. No identifiable information was included in the questions.

Results

Of the 176 surveys distributed, 92 were returned by the clinic attendees, a response rate of 52.27%. Of the surveys returned, 58 (63%) were online, and 34 (37%) were returned by post. Table 1 shows the demographic characteristics and birth history of the respondents. Table 2 presents the reasons for referral to the clinic.

The women were asked several questions about their experience of the care they received by the midwife or doctor looking after them at the clinic, using a 6-point Likert scale (‘poor’, ‘very poor’, ‘good’, ‘very good’, excellent’, ‘does not apply’). The responses to each question are presented in Table 3. Further analysis was undertaken with these questions to remove the ‘does not apply’ responses from the analysis. For the women with whom the questions did apply, approximately two thirds responded with ‘very good’ or ‘excellent’ to the various questions (61.9–70.6%). However, only 45% of participants reported ‘very good’ or ‘excellent’ care in terms of ‘helping them to take control’ and only 52.9% reported ‘very good’ or ‘excellent’ care in terms of ‘making a plan of action’. A further question using the same Likert scale was an overall rating of the clinic (Figure 1). The clinic was rated ‘excellent’ or ‘very good’ overall by 64.7% of the respondents, with 12.9% rating the clinic ‘poor’ or ‘very poor’.

More specific questions were asked in the survey about the women's experiences in the clinic. These questions used 3-, 4- and 5-point Likert scales. The answers to these questions are presented in Table 4. Further analysis was undertaken with these questions to remove the ‘does not apply’ and ‘did not need to ask’ responses from the analysis. A significant majority of the women (95.2%) reported ‘definitely’ or ‘somewhat’ having enough time to discuss their problem. Of the women who received treatment and answered the question about receiving an explanation about the treatment received, 91.8% (n=73) reported that they ‘definitely’, or ‘somewhat’, received an explanation about the treatment. Of the women who had questions, most (89.5%) of the respondents ‘definitely’, or ‘somewhat’ had these questions answered, with the remaining 10.5% reporting that they ‘did not get the opportunity to ask the questions' or ‘did not have their questions answered’. A significant majority (92.7%) of the respondents reported ‘definitely’, or ‘somewhat’, having confidence in the midwife/doctor looking after them. However, almost half of the women in the survey (47.1%) stated that the midwife/doctor looking after them did not know enough about their history when arriving at the appointment. Over 90% of the women reported feeling ‘definite’ or ‘somewhat’ involved in the clinical decisions concerning their care. In total, 55.56% of the women knew what would happen next, in terms of their treatment/assessment, with 28.4% knowing something and 16% of women not knowing what would happen next.

Open-ended questions

The final two questions in the survey gave the women an opportunity to make comments. Question 19 asked ‘are there any areas where you feel we could make improvements?’. Of the 92 surveys received, 67 women left a free-text comment. The final question read ‘please use the following section for any comments you would like to make’. A total of 39 women left a comment in this section. All comments were amalgamated. Seven comments were made that were not relevant to the clinic itself, but instead pertained to other elements of care during their antenatal or intrapartum care. These were placed in a theme and not presented here. A further nine themes were identified from the remaining 99 comments received. These themes were care and empathy, waiting times, service, knowledge of history, communication, debriefing, facilities, awareness of the clinic and improved wound healing. For the sake of flow, the comments are not presented within specific themes here.

Some of the comments were relatively general, complimenting the clinic and its staff on a good service. Several women used the opportunity to thank the members of the morbidity clinic for their service.

‘I could not fault anything with the [morbidity] clinic, they were all amazing and so understanding.’

P09

‘I'm so thankful for the [morbidity] clinic, as GPs are not experienced in this area and I honestly wouldn't have known where else to go after being sent away from the emergency department.’

P18

Care received and empathy shown to the women attending the clinic was a central theme identified from the free-text comments. A small number of comments were made regarding the lack of continuity of staff. Two women mentioned that they were seen by different staff at every visit. Several women displayed enormous gratitude for the care received and some women mentioned staff members by name, acknowledging exceptional support and empathy.

‘For 3 out of my 4 visits to the [morbidity] clinic so far I have seen [midwife manager], she has been the most caring and kind person throughout this whole experience. I was in so much pain and was so scared on my first visit as I didn't know what was wrong and her patience and kindness were out of this world.’

P14

Several women specifically mentioned the physical improvements resulting from the care received at the clinic.

‘Overall, this clinic was a huge help to me and I'm really grateful to all the midwives and the doctors there for not letting me go until I healed.’

P06

A few women referred expressly to being listened to by the staff. Two of the participants remarked positively about this, whereas two other participants requested that staff listen more.

‘The doctor I met in the [morbidity] clinic was the first person who I felt listened to me. He gave me so much time and I just wish I had gotten his name.’

P53

‘Let the patient tell their story. Understand your background first and know details about the labour/birth.’

P43

There were some criticisms of the care received. Some of the comments referred to reduced empathy, with others referring to the clinician not being thorough enough. A few women displayed disappointment when the clinician looking after them was unaware of their history or reason for their visit before entering the room. Frustration was noted in some of the comments in this theme.

‘Double check notes on personal issues raised in previous appointments before seeing the patient…I was asked at every appointment if I'd tried sex yet but had previously explained I was going through a separation.’

P18

Some statements were made to the contrary, with women remarking their satisfaction with the clinicians' knowledge about their experiences.

‘First visit to the clinic I was only waiting about 10–15 minutes and met [doctor] who knew my history – very efficient.’

P31

For some women, an explanation of what to expect after treatment was not clarified in terms of pain and healing. Furthermore, the steps to take if they were concerned was lacking.

‘If you develop future problems, I was not made aware what supports were available.’

P45

Women appreciated the opportunity to debrief and recommended more awareness and an expansion of this service.

‘I found the labour debrief invaluable and think it should be more widely used/offered/made known that service is available.’

P20

Several women suggested improvements were needed with regard to general communication and appointment times. For example, very little knowledge of the clinic was reported by some respondents. Some women noted their confusion about the appointment or appointment times, which healthcare professional they would see and where to go for the appointment within the hospital.

‘I wasn't aware the morbidity clinic was only for mothers as it didn't state this in the letter of appointment I received. Better explanation and communication needed.’

P35

Other women mentioned the lack of awareness of the clinic in the community.

‘I have mentioned the [morbidity] clinic in my local mother and baby group and nobody there - either mothers or public health nurses - has ever heard of it.’

P03

Additionally, there were a few issues noted regarding referrals, communication between departments and even within the layout of the outpatient department.

‘At reception I was told to take a urine sample bottle, but I was not informed about who to give it to. The set up was all a bit haphazard. The nurses who took the sample were friendly and helpful though.’

P15

Discussion

As patient opinion becomes more imperative in the maternity care improvement process both nationally and internationally (Manzoor et al, 2019). This morbidity clinic evaluation is ideally placed to honour the principles of patient engagement in guiding the improvement of the service provided at the clinic. Patient satisfaction surveys form a vital part of the approach to include patients in the planning and development of healthcare (Keegan and McGee, 2003). This study aimed to identify necessary improvements to the morbidity clinic to enhance women's experiences of attending the clinic in the future. In privileging women's voices and focusing on their concerns, the findings from this study highlighted that mothers value the relational aspects of the care they receive, being listened to. Inviting women to participate in this study gave women a space to voice their concerns, as recommended by O'Brien et al (2018). Most mothers were happy with their care and the feedback of positive experiences highlights the importance of providing such a service. However, there is much more knowledge to be gained from, and cognisance to be made of, the negative feedback regarding aspects of care that could be improved. Overall, nearly two-thirds of women in the study rated the morbidity clinic ‘very good’ or ‘excellent’, with 13% of women evaluating the clinic ‘poor’ or ‘fair’.

In the free-text comments, women gave positive feedback on the treatment they received. Improved healing and pain reduction were significant themes in the free-text comments. However, the physical assessment or treatment at the service was only one aspect of their experience that women found important. Some women identified the pressures in the system and highlighted that organisational communication (eg lack of detail in appointment letters and inefficient signposting in the department) and relational communication (eg limited knowledge of patient history) negatively affected some of their experience of attending the clinic. Furthermore, women value encounters with healthcare providers who display humanistic qualities, such as showing empathy and taking time to listen (Munch et al, 2020).

Research has highlighted that communication after birth receives less positive feedback from women than before and during birth (Ockleford et al, 2004; Bick et al, 2020). In the current study, 60–65% of women rated aspects of relational care, such as listening, showing care and compassion and fully understanding their concerns, as excellent or good. This relates to approximately one-fifth of women reporting dissatisfaction with some elements of care, such as ‘explain things clearly’ (19%), ‘making a plan of action’ (21%) and ‘being interested in the whole person’ (23%). The team acknowledges that these aspects of relational care need to improve, and steps are required to increase staff awareness of women's needs and wishes, particularly around these specific communication elements. The open-ended comments allowed the women to describe their experience of the care in more detail.

Despite some of the negative findings above, the comments were predominantly positive, with significant gratitude shown for the relational aspects of women's care. Building trusting relationships based on mutual respect with the women who attend the clinic and at any other point of a woman's antenatal, intrapartum and postnatal care is crucial (Newman, 2019; Menage et al, 2020). Unfortunately, the fragmented nature of maternity services in Ireland reduces continuity of care (Yoshida and Sandall, 2013), which creates a challenge to building trusting relationships and, therefore, open communication. Lack of continuity of care was described by some women as a negative component of the care provided.

In response to the information gained from the experiences of women attending the postnatal morbidity clinic, an advanced midwife practitioner in the assisted care pathway (National Maternity Strategy 2016–2026) focusing on mothers ‘considered medium–risk’ who require a higher level of care was appointed to the service. Two additional advanced midwife practitioner-led clinic days have been set up, as well as the existing consultant-led clinic. Furthermore, postnatal readmissions with wound breakdown are reviewed by the advanced midwife practitioner as inpatients. The advanced midwife practitioner assesses, triages and treats women within her scope of midwifery practice and refers women who require obstetric input or treatment. A recent qualitative study on postnatal care conducted at the National Maternity Hospital reported inadequate midwifery support for women after discharge from the hospital (Doherty et al, 2021). The participating midwives and healthcare assistants highlighted the need for additional midwifery care for women for 6–12 weeks after birth, particularly those with a complicated birth or postnatal morbidity (Doherty et al, 2021). Many women experience post-traumatic stress as a result of childbirth (Baxter, 2019). Additionally, women who receive more medical interventions during birth have an increasingly negative perception of their birth (Selkirk et al, 2006). With the nature of the morbidity clinic and its attendees, more women who attend the morbidity clinic experience an operative vaginal birth than the general population of the research site (36.16% versus 13.7%) (National Maternity Hospital, 2019). Following a review of the literature on postnatal debriefing, Skibniewski-Woods (2011) recommends ‘listening services’ as opposed to formal debriefing services, as she strongly suggests that this type of communication constitutes an emotionally supportive activity. Therefore, it is recommended that postnatal ‘listening services’ are more routinely offered to women who experience a complicated or traumatic birth so that they can better understand their experience while allowing them to share their birth stories (Baxter, 2019).

In response to clinic attendees' requests, this postnatal maternal morbidity service has now been expanded by the advanced midwife practitioner. The appointment of an advanced midwife practitioner to the morbidity clinic creates invaluable opportunities for these vulnerable women to access continuity of care while contributing to the safe space for women to discuss sensitive issues, such as sexual issues and urinary or fecal incontinence. Women and their partners can build a relationship with the midwife, discussing their birthing experience in a compassionate, safe environment, facilitating recovery on the journey through parenthood. The clinic's expansion also allows for a broader cohort of women with postnatal complications/morbidities and complex social issues to be referred for treatment, follow up and care. This is strengthened by the strong multidisciplinary relationships within the clinic, namely between the midwifery and Allied Health professionals who care for women who require further treatment.

Conclusions

Postnatal maternal morbidity clinics are an essential component of maternity care services and should be developed in every maternity unit in Ireland. The evaluation of this unique clinic was conducted to highlight areas for improvement within the service. Women's overall clinic rating was high for approximately two thirds of women. Significant areas for improvement were highlighted in the survey. These included some clinicians' lack of knowledge of patient history, the need for expansion and further promotion of the clinic nationally and more opportunities for debriefing. The appointment of an advanced midwife practitioner to the service has allowed for greater continuity of compassionate and holistic care, an expansion of the service and further opportunities for debriefing.

Key points

• Postnatal morbidity clinics are recommended in all areas, both in Ireland and Internationally.
• Women's voices must be heard in order to effectively evaluate whether a service or intervention is meeting women's needs.
• An advanced midwife practitioner in assisted care is a welcome addition to the current postnatal morbidity clinic, in order to provide more compassionate and holistic care to women with morbidities.

CPD reflective questions

• What pathway does your unit/service have in place to ensure that all women with morbidities are assessed, cared for and treated in a timely manner?
• How does your unit/service evaluate new services or interventions?
• How can your unit/service improve care for women who experience a postnatal complication or morbidity?