versão impressa ISSN 0080-6234
Rev. esc. enferm. USP v.42 n.3 São Paulo set. 2008
Unlocking the potential of effective care for life-long maternal and infant health: the need to adress the 'invisible' service after birth
Debra BickI; Maria Helena BastosII; Simone Grilo DinizIII
of Evidence Based Midwifery Practice, Florence Nightingale School of Nursing
and Midwifery, Waterloo Bridge Wing, King's College London. firstname.lastname@example.org
IIMD, MSc, Research Obstetrician, Division of Health and Social Care Research, King's College, London. email@example.com
IIIAssistante Professor, Maternal and Child Health Department, School of Public Health, University of São Paulo, SP, Brazil. firstname.lastname@example.org
There is increasing recognition among women, academics, policy makers, service providers and clinicians of the need to increase the normal birth rate. The reasons include enhanced maternal and neonatal health outcomes and more cost effective use of finite health care resources. The drive to increase normal birth is to be applauded, although ironically, in many countries, including the UK and Latin America, the normal birth rate continues to decline(1-2). Clearly, there is a long way to go before normal birth (defined in the UK as birth with no intervention at all(2) becomes a reality for many women. However the focus on normal birth may inadvertently detract key maternity service stakeholders from promoting what should be an effective continuum of care through pregnancy, birth and the postnatal period, with each phase of a woman's pregnancy and birth journey not managed or resourced as a separate entity, and no phase of the journey taking precedence over another.
Currently in the UK, the provision of care after birth continues to be accorded a relatively low priority despite accruing evidence that planned, tailored community-based midwifery care could make a significant difference to maternal psychological health in the shorter and longer-term(3). In developing countries, the provision of postnatal care still literally means the difference between life and death for a mother and her baby(4). Despite global differences with respect to the funding and organisation of healthcare systems and availability of midwifery care, the postnatal period is traditionally defined as 6 - 8 weeks after birth. It is interesting to note that evidence to support why this period of time was selected is lacking, resulting in a somewhat arbitrary period of time during which the woman is expected to have fully recovered physically and psychologically from her pregnancy and birth. It is also of note that resources for postnatal care certainly will not cover health care contacts for the full 6 - 8 week period.
The UK includes as part of its maternity services the universal provision of midwifery care after birth. Postnatal midwifery care is a legal requirement instigated when maternal mortality rates at the beginning of the 20th century remained high. Deaths from sepsis and haemorrhage were common, the use of untrained handy women who cared for women at home viewed as responsible for many deaths(5). Although midwifery postnatal care was instigated in England in 1905, universal access to midwifery services free at the point of contact was not available until 1936. The launch of the National Health Service (NHS) in 1948 firmly placed the organisation and content of maternity care and the employment of midwives within the acute care sector, and introduced payment for family doctors to provide maternity care and oversee care given by community midwives. The period leading up to the launch of the NHS 60 years ago coincided with a dramatic fall in maternal mortality rates, the improvements in public health, socio-economic conditions and availability of antibiotics all contributing to the decline in maternal deaths. Since 1948 there has been a gradual shift in place of birth in the UK from the home to the hospital, and a subsequent increase in medical intervention including caesarean section and instrumental delivery(2). Conversely, as interventions which have implications for maternal and infant morbidity and mortality have increased, resource constraints are driving a decrease in in-patient stay after birth and the number of postnatal contacts a woman and her baby will receive from a midwife at home. Few women now receive a home visit following birth from their family doctor. In the UK, we have a situation in our maternity services in which resources are so limited that resources are constantly being reviewed, with postnatal care the main area for reduction in service provision. This suggests that postnatal care is viewed as an area of less importance when compared with care during the antenatal and Intrapartum periods. But is this really the case?
Much of our knowledge of the impact of birth on women's physical and psychological health has been based on assumption. The history of obstetrics is littered with the aftermath of interventions introduced because they were assumed to be of benefit when they were later proved to be harmful or as having no particular benefit. The list of assumptions have included routine performance of episiotomy; routine electronic fetal monitoring; and routine shaving of the perineal area on admission to hospital in labour. Likewise with respect to recovery after birth there was an assumption that women would have fully recovered from birth within 6 - 8 weeks. For nearly a century after the introduction of universal postnatal midwifery care in the UK, this was the accepted case when in fact no one had actually asked women.
During the last two decades, a number of observational studies undertaken in the UK, Australia and Europe(6-8), identified widespread and persistent maternal physical and psychological morbidity, which few women volunteered to their health carer and few health carers identified. Evidence of the impact of maternal health problems after birth has since been accumulating from other high, middle and low income countries, as has recognition of the need for evaluation of maternal and infant health after birth as a public health priority, particularly in countries striving to achieve the United Nations Millennium Development Goals(9). Recent examples of recognition of the need to improve access to services after birth include a recent study from Brazil(10) which examined the prevalence of postnatal depression among women living in Porto Alegre in Southern Brazil, 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(11) and an RCT which compared outcomes among women allocated to receive home visits from specially trained midwives compared with no home visits in Damascus, Syria(12). In countries such as the USA where women may be offered one postnatal consultation with their doctor at 4 - 6 weeks after birth, attention has been given to the need to ensure how the most vulnerable women in that society least likely to attend for their postpartum visit receive the care they need(13).
One factor common to all countries which have investigated health outcomes after birth, whether in a developed or developing country, is the apparent invisibility of the postnatal period and lack of systematic recognition that care after birth is an essential continuum of pregnancy and birth care. If the maternal and infant mortality rates in developing countries are to be reduced in line with the Millennium Development Goals, postnatal care in the 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 UK, we wish to improve public health outcomes with respect to maternal mental health, improved breastfeeding uptake and duration and tackle chronic health problems caused by the burden of obesity, we need effective postnatal care and not just focus service provision on ensuring all women have one-to-one midwifery care during labour. We also require policy makers and service providers to 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.
The lack of access to effective, timely and appropriate postnatal care should be viewed as a human right. Women's health issues relating to care around pregnancy and birth have remained invisible for too long, with potential far reaching consequences arising from an inequity of care for each woman, her baby, her family and society as a whole. Where provision of postnatal services is universal, women need to be encouraged to demand the care they need and informed of ways in which services can be accessed. In countries with under provision of services, gaps in implementation of defined programmes of postnatal care as a continuum of pregnancy and birth need to be addressed if maternal and neonatal mortality rates are to be reduced in line with Millennium Development Goals(4).
All women, wherever they give birth in the world, deserve care that will ensure they and their babies have the best start to life. This does not require expensive technology. It does require planning of appropriate health systems for local need, health attendants with the appropriate competencies and infrastructure to deliver care. As we near the end of the first decade of the 21st century, priorities for our maternity services after birth have to be redefined as they are not currently meeting the needs of many women who have to suffer the physical and psychological consequences.
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