Contemporary Postnatal Care in the Twenty-ﬁrst Century ~ London Institute of Business and Management

Introduction

Duringrecentyearstheview seems to have been adopted that postnatal care, whilst a core component of midwife practice in the United Kingdom for over a century, is now more of a formality than a public health priority. A number of reasons for this can be postulated. Over the last three decades the long-term trend towards shorter inpatient stay has continued; for example, only 32% of women in 1975 were discharged home within 3 days of giving birth while in 2005–2006, 87% of women were discharged within 3 days despite the increase in medical interventions and more complex health needs of women who become pregnant. Over the same period, domiciliary postnatal contacts have also declined. In 1988–1989, the average rate per maternity in England and Wales was 9.2 postnatal contacts, declining to 7.2 in 1999–2000. In a recent survey of women’s experiences of maternity care in England in 2006, women received an average of ﬁve home visits. Despite the need for midwives to optimise the limited number of postnatal contacts they now have with women, there has been a dearth of evidence to support a practice. Furthermore, documentation of postnatal care has received limited attention with the implications of how this perpetuates the content of care not being considered, although recent studies of the care pathways to standardise decision-making in labour have commenced this dialogue.

The historical, social, cultural and economic inﬂuences on women and birth practices since the Middle Ages were described in Chapter 1.

The implications of the introduction in the early twentieth century of midwifery registration and standards for supervision and training were also outlined. One of the most signiﬁcant catalysts for midwifery and birth practices in the United Kingdom towards the end of the twentieth century was the move for all women to give birth in the hospital on the assumption that this was the safest option (Tew 1998). The subsequent impact of the transfer of birth into the acute hospital has impacted on postnatal services because of the need to maximise ﬁnite resources, reduce inpatient turn around intervals and ensure that adequate stafﬁng levels are available on labour wards. As we move into the twenty-ﬁrst century, we face new challenges of achieving safe, high-quality maternity care following a signiﬁcant shift in public health priorities, for example, chronic health problems caused by an increasingly obese population in developed countries. While postnatal care has been the subject of recent policy and guideline initiatives, major barriers remain to achieve and sustaining change. In this chapter, the role of postnatal care and its place in meeting twenty-ﬁrst century public health is addressed, reﬂecting on evidence, issues and implications for women who give birth in the United Kingdom and internationally.

Developments informing contemporary postnatal care

Despite the introduction of postnatal midwifery care at the beginning of the last century, it was not until the early 1990s that a small number of researchers began to question if the content and timing of routine care were appropriate and policymakers to review how services were organised. The dramatic decline in maternal mortality rates around the time of World War II, followed by the gradual move for all women to give birth in the hospital, did not trigger a review of the content or timing of postnatal care. The House of Commons Select Committee Report on the Maternity Services published in 1992 was prompted by widespread concerns about the fragmentation of the maternity services.With respect to postnatal care, the Committee described it as an area that was: poorly evaluated and researched, delivered in often inappropriate and fragmented ways and has a dissipated managerial focus which mitigates against effective use of resources.

An Expert Maternity Committee, established in response to the Select Committee Report to examine policy and make recommendations for change, published Changing Childbirth, which was formally adopted as government policy. Changing Childbirth recommended that research in postnatal care should be broadened, and in redesigning postnatal services, the need for continuity of care should be at the centre. In 1997, The Audit Commission, the ofﬁcial body charged with ensuring how public money is spent, published their report of an external review of the maternity services, which collected data from maternity units, general practitioners (GP) and a survey of women who had given birth in 1995. The report noted the impact that the mother’s health on her recovery and adjustment to parenthood and the need to ensure postnatal care was properly planned.

At the time of publication of these two important reports, little research had been conducted on the content or duration of midwifery postnatal care, which continued to be informed by minimal guidance. Guidance on the duration of contacts included in the ‘midwives rules’ continued to refer to a period of ‘not less than 10 and not more than 28 days after the end of labour during which the continued attendance of a midwife on a mother is requisite’, with no evidence to support why this was considered an appropriate length of time to oversee maternal recovery from birth. The content of postnatal care, introduced at the beginning of the twentieth-century when prevention of death from haemorrhage and sepsis were a priority, continued to focus on observation of uterine involution, lochia, temperature and blood pressure. This was despite medical advances (e.g. safer anaesthesia, access to contraception and antibiotics to treat puerperal infection), increased awareness of the importance of public health (e.g. better sanitation and housing) as well as advances in the social and economic status of women. A survey of midwifery practice in two English health districts, which examined the content of midwifery home visits, found that although midwives performed traditional components of care on a daily basis, they saw little value in performing them. An earlier small study of midwifery contacts found that midwives undertook a wide variety of tasks during a home visit but these were frequently not matched to women’s needs.

Another traditional component of postnatal care is the routine check with the woman’s GP at 6–8 weeks, which marks the end of maternity care. This component of care was introduced around 60 years ago when the National Health Service was launched, although evidence to support the timing and content of the check is lacking. Despite this being such a routine milestone of a woman’s ‘journey’ through pregnancy and birth, few studies have assessed the beneﬁt of the consultation. In a small study of 125 women who had routine vaginal examinations at their check found only six had any abnormality detected as a consequence, none of which required treatment. Discussion of contraception at the visit may be too late as women resume sexual intercourse earlier than previously considered. This aspect of postnatal care will be discussed further in the chapter.

Maternal physical and psychological morbidity

One reason for the lack of revision to the timing and content of routine postnatal care was the assumption that performing traditional observations and examinations would detect health problems, and women were physically and psychologically recovered from the birth at the conclusion of postnatal care. The ﬁrst observational studies of maternal health published in the United Kingdom and Australia showed that a wide range of maternal physical and psychological health problems were experienced, many of which persisted beyond the postnatal period. Furthermore, health problems were unlikely to be identiﬁed within routine postnatal care, as women did not report them and health professionals did not ask about them.

MacArthur et al. in a large study of women who gave birth in one maternity unit in Birmingham, United Kingdom, found that 47% of over 11 000 women reported one or more new health problems occurring for the ﬁrst time within 6 weeks of giving birth and that many symptoms persisted. A study undertaken in the Grampian region of Scotland found 76% of 1249 women who completed a survey experienced at least one health problems one time between leaving his capital and the eighth postnatal week. Commonly reported problems included a backache, headaches, fatigue, urinary stress incontinence, haemorrhoids, perineal pain and depression. Studies from Australia, France and Italy reported similar levels of morbidity. Furthermore, the impact and severity of health problems was also described for the ﬁrst time. Whilst problems were not life-threatening, some impacted on women’s lifestyles and relationships with their family.

Researchhascontinuedtohighlight the range and impact of maternal morbidity. Some problems are clearly related to a particular event or intervention during labour or at the time of birth, for example, having a forcepsdeliveryforaﬁrstvaginalbirthandriskofdevelopingpersistent faecal incontinence, or having a spinal epidural for labour pain relief and experiencing a post-dural puncture headache. Other problems may be related to particular maternal characteristics or the level of social support a woman may have access to; for example, women may experience a backache because she has no one to assist with caring for her other small children or with lifting heavy shopping or baby equipment or she may have a higher risk of developing depression, based on a previous history of mental health problems or poor marital relationship.

Although more is known about maternal morbidity now compared with 20 years ago, further primary and secondary research is required to assess the impact on immediate and longer-term health issues of pregnancy and birth, including the role of social, cultural and economic factors, and how models of care can be revised to meet needs. It is also important to review clinical training and ongoing staff development to optimise skills to effectively identify and manage postnatal physical and psychological morbidity.Ensuring evidence of beneﬁtis transferred and sustained in practice continues to be a challenge.

Could postnatal care be revised to enhance maternal health?

Following the publication of studies of maternal morbidity, questions were raised about whether a routine universal provision of postnatal care could enhance maternal health outcomes and what revisions to care would be necessary to achieve this. Randomised controlled trials (RCTs) undertaken in the United Kingdom and Australia assessed the impact on maternal physical and psychological health of revisions to routine care or an intervention in addition to routine care; however, only the RCT by had a positive beneﬁt as described later. RCTs of antenatal or postnatal interventions for women at risk of speciﬁc postnatal health problems (i.e. prevention of post-traumatic stress disorder) are not included here.

The intervention assessed in the RCT by MacArthur et al. was a package of care delivered by midwives. The unit of randomisation was the general practice. The trial took place across the West Midlands of England and included general practices from rural, urban and inner-city areas. The focus of the new model was the provision of planned visits over an extended period of time, tailored to women’s individual needs with a focus on the identiﬁcation and management of common health problems. Each woman received a ﬁrst home visit, a visit at around 10 days and 28 days and a ﬁnal visit at 10–12 weeks, which replaced the routine GP 6–8-week check. All other visits were to be based on need and not routine, informed by a care plan. Symptom checklists were to be used to identify problems, with evidence-based guidelines for midwives to implement ﬁrst-line management of those

Table 2.1 Randomised controlled trials of revisions to usual care to enhance maternal postnatal health.

identiﬁed. A total of 1087 women were recruited from 17 general practices randomised to the intervention and 977 from 19 general practices, which formed the control group.

Main trial outcomes were the Edinburgh Postnatal Depression Scale, with a score of 13orhigher taken as an indication that a woman was likely to be depressed, and the mental health Component Score (MCS) and Physical Health Component Score (PCS) of the SF36, a measure of general health and well-being. The outcome measures were included in a postal questionnaire sent at 4 and 12 months after the birth.

Questions on maternal health problems were included in the 12-month questionnaire. Breastfeeding duration was assessed at both time points and ‘good’ practice indicators such as uptake of infant immunisation were assessed using GP records at 12 months after the birth. A range of process outcome data was also collected to enable the study team to assess if the implementation of the new model took place (and which elements were more or less likely to be implemented) and to compare the number of midwifery visits made in the two trial groups for the cost-effectiveness analysis. Women were also asked to keep a diary to record which health professionals had visited them during the postnatal period.

The results showed a signiﬁcant difference in maternal mental health outcomes at 4and 12months after the birth. The distribution of the mean MCS scores by cluster (general practice) showed that the results were general and could not be attributed to one or two clusters with more extreme scores. This was also the case for EPDS scores. There were no differences in PCS scores at either time point. The secondary outcomes that included women’s views of care were either signiﬁcantly more positive in the new model or did not differ between the trial groups. Maternal health problems at 12 months, which were also a secondary outcome, showed signiﬁcant differences in depression, haemorrhoids and fatigue, which were less likely to be reported by women who received the new model of care, with no difference in breastfeeding outcomes. Women who received the new model of care were less likely to visit their GP during the ﬁrst year after the index birth about a subsequent pregnancy, and immunisation uptake for the study group showed a 98% uptake. The care provided within the new model was cost-effective as health outcomes were better and costs did not differ substantially.

To date, this is the only trial to have shown a signiﬁcant effect on maternal postnatal health but only on psychological and not physical health outcomes. Reasons for this could include the difﬁculty of completely resolving a physical symptom, such as a backache or urinary stress incontinence. However, the positive impact on mental health that acknowledgement of a physical symptom could have is also an important consideration. It is also plausible that women who had planned care from a midwife they knew over a longer period of time enabled them to more freely discuss their health.

The trial ﬁndings demonstrated for the ﬁrst time the impact mid-wives could make to public health from revisions to routine care. The researchers concluded that adaptation of the new model into National Health Service (NHS) care as standard was justiﬁed; however, no further work has been undertaken to evaluate if the new model could be implemented outside of an RCT and achieve the same health beneﬁts. Elements of the ‘package’ of care have been reﬂected in recent policy suchastheNationalServiceFrameworkforChildren, young people and Maternity Services and National Institute for Health and Clinical Excellence (NICE) guidance on routine postnatal care but whether this ‘piecemeal’ approach to postnatal care revision can achieve the same anticipated psychological health beneﬁts is as yet unknown. The next section of this chapter considers recent policy and practice developments for contemporary midwifery postnatal care.

Implications of policy and practice developments on contemporary postnatal care

As referred to earlier, Changing Childbirth was published following a review of the evidence presented to the House of Commons Select Committee in response to concerns about the maternity-vices. There was widespread publicity when the report was published, with many local maternity service providers establishing models of care to meet government targets based on report recommendations, such as ensuring that within 5 years at least 75% of women would know the midwife who cared for them during labour. However, the extent to which implementation of the recommendations was successful is debatable. Where reasons for lack of sustainability were offered, these frequently related to resource and funding issues. Research into pilot projects such as midwifery group practices showed that midwife ‘burn-out’ was often an issue due to having to provide continuity of care over a 24-hour period to too many women and the role of the multi-professional team in the new models of care was often unclear.

The election of a Labour government in 1997 triggered a major reform of the NHS with the drive to transform it into a service ‘ﬁt for the twenty-ﬁrst century’, an end to postcode prescribing, a focus on reducing health inequalities and measures to improve the quality of care, with a particular emphasis on priority areas such as cancer and mental health. Several major policy initiatives were published: some outlining steps to be taken to transform NHS services, others speciﬁcally aimed at reducing poor health (Saving Lives: Our Healthier Nation, DoH 1999), and some targeting speciﬁc services including maternity. A programme of structural and process reform of the NHS was undertaken, including the reorganisation of purchasing bodies, the creation of regulatory bodies such as the National Institute for Health and Clinical Excellence and the Care Quality Commission. There have been some key indicators of success, for example, a reduction in waiting times of more than 6 months for elective surgery (Maynard & Street 2006) and evidence that National Service Frameworks have improved the quality of services.

National Service Framework for Children, Young People

The National Service Framework for Children, Young People and Maternity Services was one of the most ambitious and far-reaching policy reports yet published for the maternity services. It included 11 standards for health services relevant to a child’s development through infancy, childhood and young adulthood. Standard 11 addresses the requirements of women and their families during pregnancy, birth and the postnatal period, with links to pre- and post-conception health promotion and the Child Health Promotion Programme. The overall standard for maternity care is that:

Women have easy access to high-quality maternity services, designed around their individual needs and those of their babies.

The NSF is clear about the importance and contribution of postnatal care, in parallel with antenatal and intrapartum care, as the following example demonstrates: The care and support provided for mothers and babies during pregnancy,childbirthandthepostnatalperiodhasasigniﬁcanteffect on children’s healthy development and their resilience to problems encountered later in life and the potential public health impact of high-quality services: The quality of the service provided for the half a million babies born in England every year, and their mothers thus have a long-term impact on the future health of the nation.

Recommendations for immediate and ongoing postnatal care were based on a review of the evidence by members of an expert subgroup, with a separate section on maternal mental health. The overriding theme was that postnatal care should be planned with the woman and tailored to meet her individual needs. Changes to the duration of postnatal contacts were recommended, as midwifery discharge at 10–14 days and the end of the postnatal period at 6–8 weeks were viewed as too soon to enable a full assessment of maternal health needs. Midwifery-led services could be provided for at least a month following birth or discharge from hospital and up to three months or longer depending on individual need. The midwives rules and standards published by the Nursing and Midwifery Council in 2004 did revise rules with respect to the duration of midwifery care:

‘Postnatal period’ means the period after the end of labour during which the attendance of a midwife upon a mother or baby is required, being not less than ten days and for such a long period as a midwife considers necessary.

However, Redshaw et al. foundonly7%ofover2900randomly selected women who gave birth in 2006 who returned a questionnaire reported that they received a midwifery visit after 28 days, although this had increased from 2% in 1995. Whilst this could infer that there is some ﬂexibility in the system it may also reﬂect greater needs associated with poorer general health and higher rates of intervention.

The National Institute for Health and Clinical Excellence, established as an independent organisation to assist the NHS in England and Wales to set priorities and make choices, has developed a set of guidelines to inform maternity care and women’s health. Guidance has been developed on speciﬁc aspects of NHS practice (i.e. caesarean section, antenatal care) and priority is as to enhance public health(e.g.maternal and infant nutrition). NHS trusts are expected to implement guidance, with compliance assessed by the Care Quality Commission. The challenge of how to support maternity units and staff to integrate NICE maternity service guidance into practice and standards for practice is acknowledged, given the range of national bodies producing guidance including the Royal Colleges, the Conﬁdential Enquiry into Maternal and Child Health and the Health Protection Agency to name but a few. To support the implementation of guidelines, NICE produced a range of tools including a costing report and costing template to enable units to calculate costs of implementation, based on their local population.

As a consequence of increasing evidence that routine postnatal care was not meeting women’s needs, the Department of Health and Welsh Assembly Government commissioned the National Collaborating Centre for Primary Care (NCC-PC) to develop a guideline to inform the routine postnatal care of women and their babies. The guideline aimed to identify the essential ‘core’ care all women and their babies should receive in the ﬁrst 6–8 weeks after birth. Recommendations for practice were based on the best available evidence of clinical and cost-effective care, with guidance included in the following areas:

Planning the content and delivery of care
Maternal health
Infant feeding
Maintaining infant health

Information and advice to support women to monitor and maintain their own and their baby’s health, including the importance of relevant and timely information on arrange of health areas include alongside recommendations for NHS care. The full guideline is available from www.nice.org.uk, with an abridged version for health professionals (Quick Reference Guide) and information for women, their partners or other carers.

Time bands for provision and content of care

NICE recommends that immediate care (Time Band One) should include taking a woman’s blood pressure measurement and ensuring she has passed urine within 6 hours of birth, with action to take if there are concerns. Within 24 hours of the birth, a woman should be offered information on signs and symptoms of major maternal morbidity (see a section titled Maternal Morbidity). Time Band Two refers to the content of care between 2 and 7 days post-partum, when women should be offered advice about normal recovery from birth, asked at each contact about their emotional health and well-being, their experience of common health problems and offered support and advice on attachment and positioning to breastfeed and minimise problems such as painful nipples. Management of commonly experienced problems includes ‘triggers’ for timely and appropriate referral and symptoms identiﬁed or reported by the women. Time Band Three covers care and advice provided within2–6weeksofthebirth.Women should be asked at each contact during this time about their experience of health problems, the timing and resumption of sexual intercourse, resolution of symptoms of transient psychological problems (the blues), with health professionals remaining vigilant to signs of domestic violence. All women should be advised to make an appointment for a ﬁnal postnatal check at 6–8 weeks.

Planning the content and delivery of care

The guideline recommends that all women have a documented, individualised care plan, which should be developed with the woman as soon as possible after the birth, and ideally commence during the antenatal period. The plan should be based on her previous and current history, taking all relevant factors into account. It is envisaged that by commencing postnatal care planning before the birth, women would feel more prepared and have more appropriate expectations of the impact of birth on their health. The guideline reinforces the recommendation of the NSF that each woman has a coordinating health professional, responsible for ensuring she received the right care at the right time.Thiscouldbethemidwife in the immediate postnatal period, with responsibility passing to the health visitor following midwifery discharge; however, the role could be fulﬁlled by the most appropriate health professional to meet a woman’s needs, including the GP or obstetrician.

Maternal morbidity

The section on maternal health includes guidance on signs and symptoms of major maternal physical morbidity, namely post-partum haemorrhage, pre-eclampsia and eclampsia, thrombosis and genital tract sepsis. A small number of women in the United Kingdom continue to die from these complications in the postnatal period and it is essential that health professionals and women are aware of signs and symptoms of potentially life-threatening conditions to ensure timely referral and management are instigated. As highlighted by the most recent Conﬁdential Enquiry into Maternal and Child Health report, in several cases of maternal death reviewed by the report team, clinical staff did not undertake observations or failed to act promptly on maternal symptoms of pyrexia or tachycardia. Those responsible for providing clinical care after birth, including midwives, GPs, obstetricians and staff in Emergency Departments must be aware of signs and symptoms of acute clinical illness in women after birth. Postnatal management of women who are obese and have a higher risk of thromboembolism should be planned with relevant members of the healthcare team.

The evidence is also presented on commonly experienced maternal morbidity, such as a backache, urinary stress incontinence, perineal pain and fatigue, with recommendations for ﬁrst-line management of these, and an emphasis on the need to ask women at each contact about their experience of morbidity, including their emotional health and well-being. This should include offering women an opportunity to talk about their birth experience and ask questions about their labour and birth. Full guidance on maternal mental health issues is included in a separate NICE guideline on antenatal and postnatal mental health published in 2007 and midwives should familiarise themselves with the recommendations presented.

From a midwifery perspective, the NICE postnatal care guidance means that the performance of traditional observations and examinations should not be routinely performed – the emphasis is on asking women about their health and utilising clinical skills more effectively to undertake observation and examination if there is a clinical indication or a woman reports any concerns about her health. With the emphasis on providing women and their families with information and sources of support to assist postnatal recovery, planning of contacts and the content of each contact should be more relevant to meeting the needs of individual women after birth.

Infant feeding

A major issue for public health is the lack of women who do not exclusively breastfeed for the recommended minimum of 6 months given the robust evidence of maternal and infant health beneﬁts that breastfeed-ing can confer. Reasons for early cessation such as painful breasts and insufﬁcient milk continue to be reported, which suggest poor postnatal support and lack of appropriate follow-up. The infant feeding section of the NICE guideline includes information on the need for a supportive environment for breastfeeding, with appropriate support regardless of the location of care. Breastfed babies should not be given formula feed unless medically indicated and babies should not be separated from their mothers within the ﬁrst hour of birth unless indicated for the health of the mother or her baby. Advice for women who require additional support to commence and sustain breastfeeding, for example, following caesarean section, is also included. A signiﬁcant inclusion within the guidance is the recommendation that healthcare facilities have a written breastfeeding policy and an externally evaluated structured programme that encourages breastfeeding, using the Baby-Friendly Hospital Initiative as a minimum standard.

Competencies to undertake postnatal care

The postnatal care guideline does not refer to which members of the multi-professional team should be responsible for speciﬁc postnatal contacts, despite the traditional role of midwives as the main care providers during the ﬁrst 10–14 days after birth. The guideline instead refers to the level of competency required for a contact, based on criteria included in Skills for Health, the Sector Skills Council for the UK health sector. In effect, this has paved the way for changes in the skill mix of the health teams responsible for the postnatal care, particularly the role of the Maternity Support Worker (MSW) (or Maternity Care Assistant) whose role in postnatal care was referred to in the NSF. The implications of the introduction of MSWs into postnatal care will be explored more fully in the following section.

This istheﬁrst time that national guidance on the level of competency required to undertake postnatal care has been presented, including core competencies which all staff who work with postnatal women should be able to demonstrate. Core competencies include being able to support women to breastfeed, to have an understanding of the physiology of lactation and neonatal metabolic adaptation and ability to communicate this to parents. Competency to undertake maternal and infant examination and recognise abnormalities, to recognise the risks, signs and symptoms of domestic violence and child abuse, including who to contact for advice and management in line with Department of Health guidance, are other core competencies.

Priorities and challenges facing contemporary postnatal care

The need to improve quality of care and implications of achieving this in line with ﬁnite resources continue to be the main drivers impacting on the content of postnatal care and the duration and timing of contacts a woman will receive. As highlighted earlier, although service revision is necessary to meet the needs of women with chronic ill health and complex social needs, barriers to achieving change continue to be presented. ‘Maternity Matters’ outlined the government’s commitment to the maternity services in line with an agenda for health reform: to develop a patient-led NHS that uses available resources as effectively and fairly as possible to promote health, reduce health inequalities and deliver the best and safest healthcare.

‘Maternity Matters’ proposed that women have a choice of how and where to access postnatal care, which could be in their home or in a community setting, such as a Sure Start Children’s Centre, with care delivered and coordinated according to relevant guidelines and an agreed pathway. Publication of ‘High-Quality Care for All: NHS Next Stage Review Final Report’ refers to the changes facing society and healthcare systems in the United Kingdom and globally, including increased expectations of service users, the changing nature of the disease and changing expectations of the healthcare workforce. This report has implications for commissioning of services, for ongoing quality improvement, education and training of NHS staff. Prior to the launch of the Next Stage Review, Strategic Health Authorities(SHAs)were asked to develop plans for action.With respect to postnatal services, the NHS London review in line with ‘Maternity Matters’ also referred to women receiving postnatal care at home and/or in a polyclinic. Although mooted as ‘choice’ in these documents, there is limited information of what this will constitute or how ‘choice’ will be offered to women, with a dearth of evidence as to the effectiveness of clinic provision for postnatal women. There is also concern that this model may not meet the needs of the most vulnerable women and research is urgently required.

Changes to the deployment of the maternity workforces, including the introduction of the European Working Time Directive, the reconﬁgurationofneonatalservices, policy drivers and the implementation of NICE maternity guidance are changing the boundaries of professional roles. Both ‘Maternity Matters’ and Health Care for London refer to the key role of maternity support workers in delivering timely and appropriate care. The introduction of MSWs is widespread across the United Kingdom, their role changing from undertaking clerical and physical tasks to providing clinical care, a change supported by ‘Agenda for Change’, which modernised pay systems within the NHS to reﬂect new working practices and skill mix. To date there has been little information on the role of MSW, their training needs and impact of their introduction on the role of the midwife or maternal and infant health outcomes. Sandall et al. undertook a scoping study on behalf of the Department of Health in England to provide an overview of the number, scope and range of practice, skill mix and service model agreements of MSWs. Findings were based on a structured questionnaire sent to a representative sample of NHS Trusts. Views on pertinent issues were also sought from email list members of an internal and external reference group and all regional Local Supervising Authority midwifery ofﬁcers.

The researchers found maternity service managers enthusiastic about the contribution of MSWs and the potential for their greater involvement in Sure Start and Children’s Centres Beneﬁts of the MSW role were highlighted in their support for breastfeeding as they had more time to spend with women, a role which could be provided within the acute and primary care sector. There were some issues with respect to their scope of practice, due to the lack of statutory training or suitability of the National Vocational training, with some MSWs reported being undertaking tasks such as giving drugs, taking blood and transferring emergency patients and babies, which would be regarded as midwifery duties. The delegation of duties to an MSW, ensuring midwife compliance with the NMC code of professional conduct, was also identiﬁed as an issue, as was the danger that MSW could cease to be ‘another pair of hands’ on busy labour wards and instead substitute care provided by midwives. With current stafﬁng issues and greater support needs of women who become pregnant facing the UK maternity services, it is likely that the numbers of MSW will increase, however, it is essential that regulation and training of MSWs are addressed as a priority to promote the quality and safety of care. Planned revisions to the place of postnatal care and impact on health outcomes of changes in skill mix of maternity teams should be supported by evidence of beneﬁt rather than as a short-term ‘ﬁx’ to manage ﬁnite resources.

The international perspective

At the end of the ﬁrst decade of the twenty-ﬁrst century, access to postnatal care for women in developing countries can still literally mean the difference between life and death for a mother and her baby. If a mother dies as a result of sepsis or postpartum haemorrhage, there is a high likelihood that her baby will also die. The global HIV/AIDs crisis, epidemics of tuberculosis and spread of diseases such as malaria, further reduce the odds of surviving pregnancy and birth. For women living in areas of civil disturbance and war, these issues are further compounded.

A number of studies from high-middle-and low-income countries are providing evidence of the impact of maternal mortality and morbidity, with increasing recognition of the need format Ireland infant health to be a public health priority, particularly in countries striving to achieve the United Nations Millennium Development Goals. Recent studies that have focused on the need to improve services after birth include a planned cluster-randomised trial of a community intervention using local women as facilitators to improve care during pregnancy,birth and the postnatal period in Mumbai,India , an RCT that compared outcomes among women allocated to receive home visits from specially trained midwives compared with no home visits in Damascus, Syria (Bashour et al. 2008) and a Brazilian study that examined the prevalence of postnatal depression among women living in an areas of Southern Brazil (Tannous et al. 2008). In some states of the United States of America where women may be offered one postnatal consultation with their doctor at 4–6 weeks after birth, the need to ensure how the most vulnerable women who are least likely to attend their postpartum visit receive the care they need was recently highlighted.

One factor common to all countries which have investigated health outcomes after birth is the apparent‘invisibility’ of the postnatal period and lack of systematic recognition that cares in the days and weeks after birth is an essential continuum of pregnancy and birth care. If maternal and infant mortality rates in developing countries are to be reduced in line with the Millennium Development Goals, postnatal care in the hours and days after birth to identify and manage maternal haemorrhage and sepsis are just as essential as ensuring a woman has access to a skilled birth attendant during her labour; if in developed countries such as the United Kingdom, we wish to improve publich ealthout comes with respect tomaternalmental health, improve breastfeeding uptake and duration and tackle chronic health problems caused by the burden of obesity, we need effective postnatal care.

Policy makers and service commissioners and providers should promote and protect postnatal care as an essential component of public health and ensure midwifery and other health service provider skills are optimised to meet health needs in line with national guidance. All women, wherever they give birth in the world, deserve care that will ensure they and their babies have the best start in life. Priorities for maternity services after birth have to be redeﬁned as they are not currently meeting the needs of many women, their babies or families, who have to suffer the longer-term physical and psychological consequences.