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Background: The postpartum period is critical and challenging for women, implying emotional, physical, social and spiritual changes. For a positive postpartum experience, it is important to receive consistent information and support from health professionals. However, this is not always the case, as care is more focused on the newborn, forgetting the needs of the puerperal woman., Aim: The review aimed to map the published scientific knowledge about women's needs in the postpartum period., Methods: A Scoping Review was carried out, according to the method proposed by The Joanna Briggs Institute, in the MEDLINE Complete, MedicLatina and CINAHL Complete databases, and were selected articles since 2017 that answered the research question "What is the available evidence on women's needs in the postpartum period?". For the selection of articles, the eligibility criteria were defined., Results: A total of 6,647 articles were identified. After the exclusion of duplicate articles and the application of the eligibility criteria, at the end of the process, 27 articles were included in the review. The extracted data were grouped into four categories, which summarize the needs of women in the postpartum period: support, sharing, care and preparation for the postpartum period., Conclusion: In the articles analysed, women reveal that they do not feel prepared for the postpartum period and identify several unmet needs, so health education and parenting skills training during pregnancy are essential to improve the postpartum experience and the transition to parenthood., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

Background: In Oman, there is a lack of data on utilisation, needs and women's satisfaction with care and information provided during postnatal follow-up period., Aim: To investigate postnatal follow-up care utilisation and women's needs; level of postnatal information received and satisfaction with services., Methods: A purposive sample of women (n = 500), recruited in the immediate postnatal period at one metropolitan and one regional birthing hospital in Oman. An electronic survey link was sent to participants at 6-8 weeks postnatally. Quantitative variables were analysed as frequencies and chi-squared test., Results: A total of 328 completed surveys were received; a response rate of 66 %. Most respondents were located in the metropolitan area (n = 250) and between 20 and 39 years (n = 308). Utilisation was low as women reported no need or no benefit in attending. Women's information needs were not sufficiently met by HCPs, requiring women to seek information from family and the internet to meet their needs. Satisfaction with services was mostly neither satisfied nor dissatisfied (30 %) or satisfied (30 %)., Conclusion: Postnatal follow-up care utilisation in both metropolitan and regional areas is less than optimal and not utilised as there was no advice to attend or no appointment date/time given, no benefit experienced previously, no need and information needed sourced from family or the internet. The information provided by postnatal follow-up care consumers can be used to enhance service delivery, inform future updates to the national maternity care guidelines, and provides a baseline for future evaluation and research., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2024. Published by Elsevier Ltd. All rights reserved.)

Objective: This study aimed to investigate new mothers' self-rated and perceived health problems and complications; their reasons for, and the frequency of, emergency department visits; how emergency department visits were associated with sociodemographic and obstetric factors; and new mothers' experiences of received support from the midwifery clinic., Design: A cross-sectional survey., Setting and Participants: The study was conducted at 35 of 64 midwifery clinics in Stockholm, Sweden. The study population consisted of 580 new mothers., Measurement and Findings: Descriptive statistics and logistic regression were used. New mothers experience a range of different health problems and complications during the first four weeks after giving birth. Sixteen percent sought emergency care. The odds of seeking emergency care increased for women with higher age and poorer self-rated health. Sixty-three percent of the new mothers received support from a midwife in primary care within the first four weeks after childbirth. Mothers who did not receive the support they wanted, expressed a wish for earlier contact and better accessibility., Conclusion and Implication for Practice: It is notable that 16 % of new mothers seek emergency care in the first weeks after childbirth. This study has practical implications for midwifery practice and policy. There is a need for tailored postnatal support strategies so that midwives potentially are able to mitigate emergency department visits. Further studies should look at whether the high number of emergency visits among new mothers varies throughout Sweden, and whether this may be a result of reduced time of hospital stay after childbirth or other factors., Competing Interests: Declaration of competing interest The authors declare that they have no conflicts of interest regarding competing financial interests or personal relationships that could have influenced the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: "Doing the month" is a prevalent Chinese postpartum custom which is believed to restore health after delivery. However, some traditional practices are potentially harmful for women's health., Objectives: To examine the effect of an evidence-based health education program on Chinese postpartum women's adherence to traditional practices of doing the month and the effect of adherence to doing the month on maternal physiological and psychological health., Methods: A randomized controlled trial was conducted. During December 2016-July 2017, we recruited postpartum women at a tertiary hospital. Women randomized to the intervention group received evidence-based health education within 1 week after returning home and received a second visit 1 month later. The control group received routine postpartum home visits. Adherence to doing the month was measured by the Adherence to Doing-the-Month Practices questionnaire (ADP). Maternal physical health was measured by the Chair Stand Test and Postpartum Symptom Checklist. Maternal psychological health was measured by the Edinburgh Postnatal Depression Scale (EPDS). Descriptive statistics, t-test, and chi-squared test were used to analyze the differences in scores and symptoms of the two groups., Results: We recruited 124 eligible postpartum women and 108 of them (54 intervention group, 54 control group) completed this study. The ADP score of the intervention group was significantly lower than that of the control group (p < 0.001). The number of participants in the experimental group with poor appetite and indigestion was significantly lower than that of control group. No significant differences were found in numbers of symptoms and average EPDS scores between the 2 study groups (p > 0.05)., Conclusions: Evidence-based health education can reduce postpartum women's adherence to some traditional practices of doing the month and improve women's physical health., Competing Interests: Declaration of Competing Interest There is no interest relationship involved in this study., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: There are many studies of women's experiences of care during the postnatal period, however little is known about women's expectations of postnatal care., Objective: This study explores first-time pregnant women's expectations, both ideal and real life, of postnatal care in England., Design: a descriptive, cross-sectional online survey design was used. The questionnaire took approximately 10 minutes to complete and was developed specifically for this survey. It included an informed consent section, socio-demographic questions and closed tick-box questions on where they had received information on postnatal care, and real and ideal expectations of postnatal care in hospital/birth centre and at home., Setting: The survey was hosted on the National Perinatal Epidemiology Unit website and advertised through a number of third sector and commercial organisations in 2017., Participants: Women who were pregnant, had not given birth before, were aged 16 years and over, and living in England were eligible to participate., Analysis: Survey data were analysed using descriptive statistics and, where appropriate, chi square test using SPSS Version 23. Data from open ended questions were analysed by two researchers separately then codes and themes were discussed until consensus was reached., Results: 283 women responded to the survey of whom 200 were eligible and included in the analysis. Most had received information on postnatal care from multiple sources, with pregnancy classes and midwives being most common. Most expected to stay one day or less in hospital or birth centre after normal delivery. Real life expectations were lower than ideal expectations, and hospital/birth centre real life expectations were higher than home real life expectations for physical health advice/checks and information/help with feeding. Categories developed from the open text answers were 'Respect, compassion and individualised care at a vulnerable time', 'The ward environment', 'Feeling ready for hospital discharge' and 'Help to find support in the community'., Key Conclusions: Women in this survey had high ideal world expectations of their postnatal care but in real life expected more focus on checking on their health and that of their baby and on giving information about the new challenges of how to breastfeed and look after a baby. While women valued checks of their health and that of their baby, ideally they wanted easy access to reassurance that they were feeding and looking after their baby well, that they were 'doing it right', and that what was happening to them was normal., Implications for Practice: As well as the necessary checks in the immediate postpartum period, consideration also needs to be given to the best way to meet the informational and support needs of women to optimise their wellbeing and transition to parenthood. A number of resources are used by women that could be enhanced to inform expectations of postnatal care and to provide valuable information to support their postnatal care., Competing Interests: Declaration of Competing Interest None declared, (Copyright © 2020. Published by Elsevier Ltd.)

Objective: To explore care workers' experiences with a flexible planning of home-based postpartum care as an innovative instrument to facilitate more client-centred care., Design: A mixed-methods design with a primarily qualitative approach followed by a quantitative follow-up, according to the Priority-Sequence model., Setting: This study is part of a larger research project researching the health effects of a flexible planning in postpartum care. The new planning enables clients and care workers to spread and/or pause the care over 14 days postpartum instead of the standard planning of eight to ten consecutive days., Participants: Maternity home care workers who provide care according the flexible planning. Eight care workers were interviewed, another eight care workers participated in the focus group discussion, and 59 care workers filled in the survey., Findings: Two main unintended consequences of the flexible planning were found: 1. care workers experienced an undesirable 'shift in their tasks' along the course of the postpartum period and 2. were heavily worried about 'making enough contracted hours'. Consequently, care workers unwillingly performed much more domiciliary activities compared to the standard planning, especially during the final days of care., Key Conclusions: The predominant nursing tasks and responsibilities of care workers appeared insufficient to respond to clients' altering needs. In addition, shorter working days and on-call duties caused an undesired excessive high-level of flexibility among care workers. Consequently, care was paradoxically determined by organisational structures rather than clients' individual needs., Implications for Practice: Our study elucidated that co-creation together with health professionals is a prerequisite for successfully implementing innovations as their way of working and personal lives are profoundly affected., Competing Interests: Declarartion of Competing Interest No conflict of interest has been declared by the authors., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objective: To explore the quality of life (QOL) and related factors in early postnatal women., Design: A descriptive, cross-sectional study., Setting: Liwonde, Malawi., Participants: Women who underwent a normal vaginal birth (N = 173) were included from August to September 2018., Measurements: The QOL of participants was assessed using a World Health Organization QOL instrument. Demographic, obstetric, and health variables were collected using a structured questionnaire. Childbirth fear and depression were respectively assessed using the Wijma Delivery Experience Questionnaire and the Edinburgh Postnatal Depression Scale. A multiple linear regression was used to examine factors associated with the QOL., Results: The mean age of participants was 29 (standard deviation 6.7) years. The overall QOL and health were satisfactory. The mean score of the QOL was highest in the psychological health and social relationships domains, followed by the environmental and physical health domains. A higher educational level was negatively related to the physical health of QOL (p ≤ 0.01), with physician care positively related (p = 0.01). The employment status was positively related to psychological health and the environmental QOL (p ≤ 0.01). Furthermore, a higher income, and physician care were positively related to the environmental QOL (p ≤ 0.05). High levels of childbirth fear and depressive symptoms were negatively related to all domains of the QOL (p ≤ 0.05), except for the social relationships domain., Conclusion and Implications for Practice: The physical health QOL was lower in postnatal mothers in Malawi. Measures to improve physical health aspects and address women's fears and depressive symptoms during postpartum care are warranted. The findings should alert the health providers of the importance of assessing and improving women's physical health and psychological well-being during postpartum care., Competing Interests: Declaration of Competing Interest No conflict of interest is declared by the authors., (Copyright © 2020. Published by Elsevier Ltd.)

Decision-making power and access to and control over resources are key elements of women's bargaining power within a household, and plays an important role in improving healthcare seeking behaviours for women and their children, which in turn augment maternal and child health outcomes. We examined the relationship between intra-household bargaining power and utilization of postnatal and child healthcare services within 6 months after delivery, based on cross-sectional survey data from Kyenjojo district, Tooro sub-region of Western Uganda. We assessed independent associations between women's intra-household bargaining autonomy and postnatal care attendance using a modified Poisson approach for common outcomes. We found that women who contributed to the decision-making processes on child healthcare, personal healthcare, and how to raise money for healthcare of family members were about 20% more likely to attend postnatal and child healthcare within 6 months of delivery, compared with women who were unable to make such decisions. Therefore, contributing to efforts that empower women to have greater control over child and personal healthcare through gender transformative approaches and policy engagements in important., Competing Interests: Declaration of Competing Interest All the authors declare no conflict of interest., (Copyright © 2020. Published by Elsevier Ltd.)

Competing Interests: Declaration of Competing Interest None.

Background: Early initiation of breastfeeding and exclusive breastfeeding can reduce infant mortality. Breastfeeding support interventions such as counselling may improve adherence to recommended practices. However, it is not known if these interventions work at the population level., Objective: The aim of this study was to assess the relationship between early postnatal breastfeeding support and recommended breastfeeding practices., Design/setting: We pooled data from 11 Demographic and Health Surveys in Africa (n = 7), South East Asia (n = 2), the Americas (n = 1), and Europe (n = 1) to analyse these associations at the population level., Participants: We limited the data to the most recent live births in the two years before the survey, including 41,431 births., Analysis: We fitted three multivariable logistic regression models to estimate the relationship between early postnatal breastfeeding support (a newborn postnatal check within an hour of birth plus counselling and observation of breastfeeding within two days) and three breastfeeding outcomes (early initiation of breastfeeding, absence of prelacteal feeding, and exclusive breastfeeding), adjusting for sociodemographic characteristics and birth-related factors., Findings: Early breastfeeding support was associated with a 24% increase (OR=1.24 95%CI=1.11,1.39) in the odds of initiating breastfeeding within one hour of birth. No relationships were found between breastfeeding support and prelacteal feeding in the first three days or exclusive breastfeeding at six months., Key Conclusion: While postnatal breastfeeding counselling and observation may improve early initiation of breastfeeding, impact is not persistent for longer term breastfeeding outcomes., Implication for Practice: Improved training for breastfeeding support and an enabling policy environment are required to improve breastfeeding practices for women and newborns., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflicts of interest. The contents expressed in the article are those of the authors and do not necessarily reflect the policies or views of the organisations they are affiliated with., (Copyright © 2019. Published by Elsevier Ltd.)

Providers' adherence to case management protocols can affect quality of care. However, how and why protocols are adhered to by frontline health workers in low- and middle-income countries is not always clear. This study explored midwives' adherence to national postnatal care protocols in two public hospitals in Southern Ghana using an ethnographic study design. Ninety participant observations and 88 conversations were conducted over a 20-months period, and two group interviews held with the midwives in the two hospitals. Data was analysed using a grounded theory approach. Findings: Midwives collectively decided when to adhere, modify or totally ignore postnatal care protocols. Adherence often occurred if required resources (equipment, tools, supplies) were available. Modification occurred when midwives felt that strict adherence could have negative implications for patients and they could be seen as acting 'unprofessionally'. Ignoring or modifying protocols also occurred when midwives were uncertain of the patient's health condition; basic supplies, logistics and infrastructure needed for adherence were unavailable or inappropriate; or midwives felt they might expose themselves or their clients to physical, psychological, emotional, financial or social harm. Regardless of the reasons that midwives felt justified to ignore or modify postnatal care protocols, it appeared in many instances to lead to the provision of care of suboptimal quality. Conclusion and recommendations: Providing clinical decision-making protocols is not enough to improve mother and new born care quality and outcomes. Faced with constraining conditions of work, providers are likely to modify guidelines as part of coping behaviour. Addressing constraining conditions of work must accompany guidelines. This includes adequate risks protection for health workers and clients; and resolution of deficits in essential equipment, infrastructure, supplies and staffing., Competing Interests: Declaration of Competing Interest None., (Copyright © 2019. Published by Elsevier Ltd.)

Objective: There is ongoing poor evaluation of post-birth care and an urgent need to improve women's satisfaction. To develop and evaluate an acceptable and useable post-birth care plan template through collaboration with women and community midwives., Design: Qualitative methodology using an action research design., Setting and Participants: North East Scotland. 10 pregnant women and 6 community midwives., Findings: Seven themes emerged from thematic analysis that informed the format of the PBCP template: being prepared for transitions, physical needs, psychosocial needs, cultural, religious and spiritual needs, organisation of care information, knowledge transfer, financial information and guidance., Key Conclusions: Women and midwives recognised the benefit of using a PBCP to ensure all information is covered and that care is individualised and organised according to cultural, social and physical needs, especially when there is fragmentation of services. The open conversational style of the PBCP provides opportunity to explore post-birth needs and how they develop over time., Implications for Practice: PBCPs provide an opportunity for women to explore their post-birth needs with their midwife, enabling them to have meaningful, respectful conversations with their midwives during the antenatal and post-birth period. This has the potential to increase women's satisfaction with their care and is particularly pertinent in regions where fragmentary systems of care are prevalent., Competing Interests: Declaration of Competing Interest None., (Copyright © 2019. Published by Elsevier Ltd.)

Objective: Volunteer breastfeeding support groups are deemed effective in promoting breastfeeding initiation and duration, but women's views are not well reported. The aim of this study was to explore women's experiences of Breastfeeding Support Groups in Ireland from their perspective., Design and Participants: Semi-structured interviews with 15 breastfeeding mothers were conducted with participants recruited as part of a larger mixed-methods study., Methods: Interviews were conducted online. Interviews were audiorecorded, transcribed, and analysed using Thematic Analysis. Cultural Historical Activity Theory was used as the theoretical framework., Findings: Six key themes were identified: 'complexity of breastfeeding support', 'community and connection', 'impact of culture on breastfeeding needs', 'the journey', 'passing on', and 'what mothers want'. Mothers primarily attend in order to meet other mothers, and not necessarily with a problem, getting practical suggestions to meet their individual and changing needs. The social aspect of support groups fosters a sense of community and inclusion, long-standing friendships, a social outlet, and ongoing support., Conclusions: Mothers attend breastfeeding support groups in order to meet other mothers and continue to attend for this reason to get mothering and breastfeeding support, as well as passing on their knowledge and experiences to other mothers, while meeting their social needs., Implications for Practice: More resources, acknowledgement and funding are needed to provide breastfeeding support groups in local communities. Breastfeeding support groups and health professionals need to emphasise the social aspects of the interactions at these group rather than attending for a breastfeeding problem., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Previous studies in Tanzania have shown that mothers do not often receive the recommended number of postnatal contacts, which limits their ability to not only have health checks but also to be provided with sufficient and quality postnatal education. Educating mothers while in the hospital is important yet there remains a paucity on the experiences of mothers in a hospital setting related to newborn care education. Therefore, the objective of this study was to explore the experience of newborn care discharge education at a national hospital in Dar es Salaam, Tanzania from the perspective of mothers and nurse midwives., Methods: Using convenience sampling, participants were recruited from Muhimbili National Hospital. Eight mothers who recently gave birth and eight nurse midwives working on the postnatal and labour ward participated. In-depth semi-structured interviews were conducted in Swahili and transcribed and translated into English. Interviews were analyzed using thematic coding., Results: Most mothers were multiparous (75%) and averaged 29.6 years of age (SD = 5.1). Nurse midwives had an average of 10 years of experience (SD = 7.5). The primary themes identified included barriers, facilitators, and opportunities related to newborn care discharge education. Barriers included lack of standard postnatal education guidelines; community norms against hospital teaching; gaps in hospital care; and expectations of mothers' previous knowledge. Facilitators identified were that education was already being provided on some relevant newborn care topics; nurse midwives desired to teach; and mothers desired to learn and build on their previous knowledge and confidence. Opportunities to improve included developing standardized guidelines related to postnatal discharge education; training nurses how to engage mothers and families; and engaging mothers through varied learning methods., Conclusion: While mothers received some education prior to discharge and nurses expressed a desire to teach, challenges remained in receiving sufficient education on all recommended postnatal education topics. Opportunity to improve postnatal education can be addressed through the development of standardized education and engaging mothers through preferred learning methods., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objective: We aimed to explore midwives' perspectives on post-abortion care (PAC) in Uganda. Specifically, we sought to improve understanding of the quality of care., Design: This was a qualitative study using individual in-depth interviews and an inductive thematic analysis., Setting and Participants: Interviews were conducted with 22 midwives (the 'informants') providing PAC in a public hospital in Kampala, Uganda. The narratives were based on experiences in current and previous workplaces, in rural and urban settings., Findings: The findings comprise one main theme - morality versus duty to provide quality post-abortion care - and three sub-themes. Our findings confirm that the midwives were committed to saving women's lives but had conflicting personal morality in relation to abortion and sense of professional duty, which seemed to influence their quality of care. Midwives were proud to provide PAC, which was described as a natural part of midwifery. However, structural challenges, such as lack of supplies and equipment and high patient loads, hampered provision of good quality care and left informants feeling frustrated. Although abortion was often implied to be immoral, the experience of PAC provision appeared to shape views on legality, leading to an ambiguous, yet more liberal, stance. Abortion stigma was reported to exist within communities and the health workforce, extending to both providers and care-seeking women. Informants had witnessed mistreatment of women seeking care due to abortion complications, through deliberate care delays and denial of pain medication., Key Conclusion and Implications for Practice: Midwives in PAC were dedicated to saving women's lives; however, conflicting morality and duty and poor working conditions seemed to impede good-quality care. Enabling midwives to provide good quality care includes increasing the patient-midwife ratio and ensuring essential resources are available. Additionally, efforts that de-stigmatise abortion and promote accountability are needed. Implementation of policies on respectful post-abortion care could aid in ensuring all women are treated with respect., (Copyright © 2019. Published by Elsevier Ltd.)

Introduction: Zuò yuèzi, or 'doing the month', is a postpartum tradition among ethnically Chinese women, and the purpose is to restore the organ and endocrine function of the mother's body to normal. The period for 'doing the month' is generally between 30 and 40 days postpartum, and some problems in the establishment of the mother-child relationship and adaptation to motherhood may occur during this period. Yet, this is an easily often-ignored period for caring. This "doing the month" period refers to the Chinese postnatal confinement of the nursing mother for one month immediately following the birth of the child, known as zuò yuè zi and has many strict traditional guidelines. There are even specialty private women's "hospitals" set up for the one-month stay catering to the nursing mother, though new mothers may also experience the postpartum period at home with home or family relative care., Aim of Study: To explore the transition to motherhood and the role of the feelings and experiences of primipara 'doing the month' period., Design: A qualitative research methodology was utilized to conduct the research. In-depth interviews were conducted., Setting: The study was conducted in a zuò yuè zi area in Taiwan, from March 2016 to March 2017., Participants: Twenty healthy primiparas were recruited using a purposive sampling method, a snowball sampling method, and were interviewed during 'doing the month' period., Findings: The change from being a childless adult to being a mother experienced by the participants during 'doing the month' period was divided into two themes: 'Motherhood burden' and 'Motherhood adaptation'. 'Motherhood burden' contained the following subthemes: 'motherhood stereotypes', 'fatigue', and 'frustration'. By contrast, motherhood adaptation contained the following subthemes: 'compromising in the face of reality' and 'being practical and realistic'., Key Conclusions and Implications for Practice: Two of the challenges of role transition around women's experiences of initiating breastfeeding for the first time during 'doing the month' period are psychological burden and acceptance of maternal responsibilities. Therefore, the needs of primiparous women transitioning to motherhood during 'doing the month' period must be considered to ensure that such women are sufficiently prepared and competent as mothers and to promote the establishment of mother-child relationships., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objective: many cultures have a set time of traditional rest in the postpartum period. There is limited information on how this activity may potentially increase the risk of venous thromboembolism (VTE). We aimed to investigate VTE risk by determining the prevalence of the cultural practice of postpartum "lying-in", quantifying activity and determining the factors that influence this tradition in women from China and the Indian subcontinent (India, Bangladesh, Pakistan and Sri Lanka) at an Australian tertiary referral hospital., Design: we surveyed a prospective cohort of 150 women aged ≥ 18 years who self-identified culturally as from the Indian subcontinent or Chinese, at baseline (≥ 32 weeks gestation) and at follow-up (six to eight weeks postpartum). Demographic details collected included VTE risk factors such as caesarean section, lack of graduated compression stockings (GCS), postpartum haemorrhage greater than 1000mL, comorbidities and immobility. We quantified postpartum activities and investigated factors that might influence inactivity., Results: there were 100 women identifying as from the Indian subcontinent and 50 women identifying as Chinese recruited at the baseline of over 32 weeks' gestation. Most of the study participants (85%) rested in the postpartum period for cultural reasons. Of the women surveyed, 51% rested in bed as much as possible in the postpartum period. We found a significant correlation between increased number of children and decreased overall immobility or rest (P = 0.03). Overall, 91% of participants had relative live-in help, and this significantly increased the risk of immobility by more than six-fold (odds ratio [OR], 6.17; 95% CI, 1.6-23.5; P = 0.008). Furthermore, a vaginal compared to a caesarean birth increased immobility risk by almost 3.5 times (OR, 3.4; 95% CI, 1.20-9.4; P = 0.021)., Conclusions: acculturation is highly individualised, however postpartum rest remains prevalent in women who identify themselves culturally as from the Indian subcontinent or as Chinese. Inactivity and comorbidities compounded the impact of cultural postpartum rest, and put women at increased risk for VTE., Implications for Practice: targeted, culturally appropriate, postnatal education should include VTE-prevention information to women who intend to practise postpartum rest., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objectives: Mothers have a great need for information during the postnatal period. Trying to meet this need, mothers are increasingly turning to the Internet. Nevertheless, many women have stated that they often or always found that the information that they found on the Internet was incomplete or wrong. Many women therefore believe that health professionals should suggest reliable Internet websites for new mothers. The aim of this study was therefore to find a consensus on the content of a reliable and centralized website dedicated to mothers from the end of pregnancy to 1 year after childbirth., Design: Two rounds of an online Delphi survey were used in this study., Setting and Participants: The panel of participants involved in the survey included parents (both mothers and fathers) and professionals (health professionals and professionals of early childhood for mothers of children aged 0 to 2 years)., Findings: Ninety-six parents and professionals participated in the first round (37.7 ± 9.76 years; 84.4% of women) and 78 in the second round. The majority of participants (94.6%) thought that a centralized website could help mothers from pregnancy to one year after childbirth. The content that the experts would like to find on a website were themed into five categories: "infants' information", "parents' information", "administrative information", "professionals' information" and "type of resources". In each category, experts highlighted the key words that they found important and should be reported on the website. The most important items highlighted by participants were baby's feeding/breastfeeding (92.8%), babies' needs (84.1%), baby blues (77.9%), postpartum depression (72.1%), management of the couple's relationship (72.1%), women's right to postnatal care (83.6%), links to reliable documents (63.9%) and a list of useful contacts (52.5%)., Conclusions: This study helped to understand the questions that mothers ask themselves during the postpartum period and provided priorities to respond to their questions in the process of developing a website., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: To compare two care models of high-risk pregnant women--a House for Pregnant Women, staffed by nurse-midwives, versus a traditional care model in a hospital maternity ward., Design: This was across-sectional study conducted in two reference maternity hospitals for high-risk pregnancies, in Belo Horizonte, Minas Gerais, Brazil. The sample consisted of 312 high-risk pregnant women consecutively admitted from January 1st to December 31 st , 2010, either to the House for Pregnant Women (n=247), or the hospital maternity ward (n=65). Gestational ages varied from 22 weeks to 36 weeks and six days. We measured individual, demographic, obstetric, labour and delivery variables, and newborn characteristics. For data analysis, we used descriptive, bivariate and multivariate statistics using Poisson regression, with a 5% significance level., Findings: At the conventional hospital maternity ward, more women had six or more antenatal exams, greater frequencies of diagnosis related to blood pressure, and a greater number of women underwent either a C-section or a vaginal delivery with an episiotomy and analgesia. At the House for Pregnant Women, the majority of the hospitalizations were related to preterm labour and premature rupture of membranes. There were no statistical differences in the newborn characteristics., Key Conclusions: The House for Pregnant Women care model, utilizing midwives was less interventionist, yet with results as favorable as in a conventional maternity hospital setting., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: the Four-Dimensional Symptom Questionnaire (4DSQ) measures four dimensions of common psychopathology: distress, depression, anxiety and somatization. The instrument is developed and validated for general practice. A previous validation study of the 4DSQ for midwifery practice indicated that pregnant women respond differently to the items of the 4DSQ. This phenomenon is called item bias. The present study is a followup validation study in which pregnant women were followed up until one year post partum, to assess pregnancy-related item bias., Design: cohort study with repeated measurements., Setting and Participants: the research group consisted of participants of the Mom@Work study, a study concerning mental health in a group of 574 working pregnant women and young mothers, recruited between 2004 and 2006. Measurements in the research group took place at 33 weeks of pregnancy and post partum at 7, 13, 25 and 52 weeks. The comparison group consisted of female general practice patients, matched for age (N=835)., Measurements and Findings: pregnancy-related item bias was assessed by two methods of differential item functioning (DIF) analysis: ordinal logistic regression (OLR) and the Mantel-Haenszel (MH) method. The impact of item bias on total scale scores was estimated by linear regression. Impact of item bias was found in the somatization-, distress- and anxiety scales of the 4DSQ across the perinatal period up until 13 weeks post partum. The depression scale remained free of item bias., Key Conclusions and Implications for Practice: pregnant and postpartum women responded differently to the 4DSQ than the women in the comparison group up until 13 weeks post partum. Pregnancy-related item bias lead to overestimation of distress and underestimation of somatization and anxiety. The depression scale was free of bias. The 4DSQ is a valid tool for case-finding and assessment of psychological conditions in the perinatal period, provided cut-off points are adapted up until 13 weeks post partum. Validation of generic questionnaires is recommended before using them in the perinatal period., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objective: to identify the emotional and support needs of pregnant multigravida women who have experienced adverse responses associated with a previous childbirth experience., Setting: four maternity hospitals in North-West England., Design: 100 surveys were distributed at an anomaly scan clinic in each of four maternity hospitals (total n=400). The survey included an adapted version of a Post-Traumatic Stress Disorder Symptom Scale to explore trauma responses at two broad time points: (a) following a previous birth and (b) during the current pregnancy. Participants were also asked about the optimal time to receive support post-birth, and the type and provider of support they had accessed/would have liked to access. Descriptive and inferential statistics were undertaken on the quantitative data. The qualitative data were analysed using a basic thematic approach., Participants: multigravida pregnant women aged 18+ years., Findings: the overall response rate was 28% (n=112); 43% (n=46) of the women had experienced negative/trauma responses associated with a previous birth, 74% of whom (n=34) continued/re-experienced adverse responses in their current pregnancy. Most commonly reported trauma responses were difficulties in recalling the previous birth(s), avoiding memories associated with it, and the distress associated with these memories when they were recalled. Approximately 54% (n=25) had received some form of support post-birth, and variations in preferred timing of postnatal support provision were reported. Information on available support and opportunities to discuss the birth with a maternity professional were identified most frequently as preferred support options., Conclusion and Implications for Practice: women's views about what might work should form the basis for effectiveness studies in this area. Among the participants in this study there was evidence of unmet support needs relating to negative or traumatic responses to a previous birth. The range of preferred timing and types of support indicate that flexible needs-based support options should be provided. Further research should assess if these findings are reinforced in a more diverse sample with a higher response rate., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Introduction: In 2003 the World Health Organization (WHO) recommended that infants should be fed exclusively with breast milk until the age of six months. However, breast feeding rates remain lower than recommended. The crucial period for breast feeding support is the first two weeks after birth. During this period breast feeding support from the midwife is needed. The aim of this paper is to gain an in-depth understanding of the role of midwives in their support of breast-feeding women, from their own perspective., Methods: Two researchers independently conducted a systematic and comprehensive literature search. Studies needed an empirical qualitative research design (1), had to focus on the role of the midwife in the support of the breast-feeding woman from the midwife's perspective (2), and had to be published between January 2005 and December 2014 (3) in order to be included. Language restrictions were English, Dutch, German and French. Eight qualitative research studies were included, using mainly focus group and in-depth interview studies, which were reported in 11 papers representing 231 midwives and 24 maternity nurses. All but one study concerned midwives working in hospital settings. A critical appraisal was performed of each study., Findings: Midwives value breast feeding education and breast feeding support as a significant part of their role as a postnatal midwife. However, the ways in which a midwife approaches and supports the breast-feeding woman vary. We distinguished two perspectives: 'the midwife as technical expert' and 'the midwife as a skilled companion'. The 'technical expert' midwife is mainly breast centred, focuses on techniques, uses the hands on approach and sees a woman as a novice. The 'skilled companion' midwife is woman centred, focuses on the mother - infant relationship and uses a hands off approach during the breast feeding support. The midwives working in a hospital setting face many barriers when performing breast feeding support, such as time restraints, which makes it difficult for them to carry out their preferred role as a 'skilled companion'. These barriers can influence the breast feeding support negatively. Supporting factors, such as evidence based breast feeding guidelines, have a positive influence on the breast feeding support., Conclusion: On the basis of findings of a synthesis of qualitative research studies, we conclude that the majority of the midwives provide breast feeding support as a technical expert and a minority as a skilled companion. Midwives prefer to be a skilled companion but face many barriers in their working contexts., (Copyright © 2016. Published by Elsevier Ltd.)

Objective: the aim of this study was to investigate new parents׳ experiences of early postnatal discharge., Design: a meta-synthesis including 10 qualitative studies was conducted using Noblit and Hare׳s method of meta-synthesis development., Setting: qualitative studies performed in western countries from 2003-2013 were included., Participants: the 10 included studies involved 237 mothers and fathers, first time parents as well as multiparous., Findings: we identified four overlapping and mutually dependent themes reflecting the new parents׳ experiences of early postnatal discharge: Feeling and taking responsibility; A time of insecurity; Being together as a family; and Striving to be confident. The mothers׳ and fathers׳ experiences of responsibility, security and confidence in their parental role, were positively influenced by having the opportunity to be together as a family, receiving postnatal care that included both parents, having influence on time of discharge, and getting individualised and available support focused on developing and recognising their own experiences of taking care of the baby., Conclusions and Implications for Practice: the new parents׳ experiences of early discharge and becoming a parent were closely related. Feeling secure and confident in the parental role was positively or negatively influenced by the organisation of early discharge. This underscores the importance of the way health professionals support new mothers and fathers at early postnatal discharge., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

This commentary discusses the 10th Step of the Baby-Friendly Hospital Initiative (BFHI), the only step that goes beyond the hospital to provide for the mother to receive breast-feeding support after she returns to the community. The reasons why such support is needed, and how this support has been provided in different settings, will be discussed. Post-discharge support for breast-feeding mothers takes many forms and is optimised when mothers can access both professional and peer support. The mother-baby dyad is best served by the right advice from the right person at the right time. Midwives who assist the new mother with information about easily accessible support in the community enable the care she has received during her short hospital stay and during any midwifery home visiting to continue when she is in an environment that may not be supportive of breast feeding., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: a move towards earlier postnatal discharge raises the challenge of finding new ways to support families when they are discharged early after childbirth., Aim: to explore how postnatal parents experienced the use of telemedicine following early discharge from hospital (i.e. 24 hours after childbirth) by investigating if they consider that their postnatal needs are met, and whether or not they experience a sense of security and parental self-efficacy., Design: intervention followed by a qualitative interview study. The intervention took place on a postnatal ward with approximately 1000 births a year. An app including chat, a knowledgebase and automated messages was trialled between postnatal parents at home and the hospital. Parents had access to the app for seven days after discharge., Population: 42 new mothers were recruited from the postnatal ward in accordance with the inclusion criteria (i.e. discharged within 24 hours of childbirth). Both parents were invited for interview., Methods: 42 sets of parents participated in the trial, and 28 sets agreed to be interviewed. Interviews (n=28) were conducted with 27 mothers and 11 fathers. Parents were interviewed together in 10 cases, 17 mothers were interviewed alone, and one father was interviewed alone. The data analysis was inspired by systematic text condensation based on Giorgi׳s descriptive phenomenological method., Findings: parents were confident in use of the app, and did not experience any barriers in contacting the nurses via asynchronous communication. Parents received timely information and guidance by communicating online, and felt that their follow-up support needs were met., Conclusions: parents viewed the app as a lifeline, and saw it as a means of informing and guiding them following early discharge from hospital after childbirth. As such, this app shows potential for enhancing self-efficacy and postnatal sense of security., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objective: to explore the factors that influence breast-feeding practices in obese women who had either stopped breast-feeding or were no longer exclusively breast-feeding 6-10 weeks following the birth of their babies, despite an original intention to do so for 16 weeks or longer. Specifically (i) to identify the barriers to successful breast-feeding and reasons for introducing formula and/or stopping breast-feeding, and (ii) to explore the women׳s views and experiences of current breast-feeding support services., Design: descriptive, qualitative study comprising semi-structured face-to-face interviews. Interviews were audio recorded and transcribed. The data were analysed using thematic analysis., Setting: participants recruited from one large maternity unit in Scotland and interviewed in their homes., Participants: 28 obese women at 6-10 weeks following birth., Findings: three major themes emerged from the data analysis: the impact of birth complications, a lack of privacy, and a low uptake of specialist breast-feeding support. Impact of birth complications: 19 of 28 women had given birth by caesarean section and some felt this led to feeling 'out of it' post-operatively, a delay in establishing skin-to-skin contact, and in establishing breast-feeding. Lack of privacy; several women described reluctance to breast feed in front of others, difficulties in achieving privacy, in hospital, at home and in public. Low uptake of postnatal breast-feeding support; despite experiencing problems such as physical difficulties during breast-feeding or a perception of low milk supply, breast-feeding support services were underused by this sample of women. A small number of the women in this study used breast-feeding clinics and reported finding these useful. A further small number felt they benefitted from the support of a friend who was successfully breast-feeding., Conclusion and Implications for Practice: midwives should be mindful of the presence of additional factors alongside maternal obesity, such as caesarean delivery, physical difficulties when breast-feeding, poor body image, and lack of confidence about sufficient milk supply. Scope for innovation within hospital policies with regard to both the facilitation of early skin-to-skin contact and privacy in postnatal accommodation could be explored in future research. Women should be provided with information about the provision and specific purpose of breast-feeding support groups and services and encouraged to access these services when appropriate. Future research could assess the usefulness of sustained breast-feeding support by health professionals, as well as partner involvement and formal peer support for this group of women. The education and training needs of health professionals in terms of supporting this group of women to breast feed may also usefully be explored., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objective: to explore midwives' experiences and perceptions of skin-to-skin contact between mothers and their healthy full-term infants immediately and during the first day after caesarean section., Design: qualitative interviews with semi-structured questions., Setting and Participants: eight midwives at three different hospitals in Stockholm participated in the study. All participants provided care for mothers and their newborn infants after caesarean birth., Analysis: transcribed material was analysed and interpreted using qualitative content analysis. The analysis yielded the theme 'fighting an uphill battle'., Findings: skin-to-skin contact was considered to be important, and something that midwives strove to implement as a natural element of postnatal care. However, in daily practice, midwives experienced many obstacles to such care, such as lack of knowledge among parents and other professionals about the benefits of skin-to-skin contact, the mother's condition after the caesarean section, and other organisational difficulties (e.g. collaboration with other professionals, lack of time). Introducing more skin-to-skin care was a challenge for the midwives, who sometimes felt both dismissed and disappointed when they tried to communicate the benefits of this type of care., Conclusion: skin-to-skin contact is not prioritised because many health care practitioners are unaware of its positive effects, and their care reflects this lack of knowledge. There is a need for education among all health care practitioners involved in caesarean procedures. Another difficulty is that many parents are unaware of the benefits of skin-to-skin contact. Maternity outpatient clinics need to inform parents about the benefits of such care, so mothers will understand the importance of skin-to-skin contact., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Objective: to develop a breast feeding assessment tool to facilitate improved targeting of optimum positioning and attachment advice and to describe the changes seen following the release of a tongue-tie., Design: development and validation of the Bristol Breastfeeding Assessment Tool (BBAT) and correlation with breast feeding self-efficacy., Setting: maternity hospital in South West England., Participants: 218 breast feeds (160 mother-infant dyads); seven midwife assessors., Findings: the tool has more explanation than other tools to remind those supporting breast-feeding women about the components of an efficient breast feed. There was good internal reliability for the final 4-item BBAT (Cronbach's alpha=0.668) and the midwives who used it showed a high correlation in the consistency of its use (ICC=0.782). Midwives were able to score a breast feed consistently using the BBAT and felt that it helped them with advice to mothers about improving positioning and attachment to make breast feeding less painful, particularly with a tongue-tied infant. The tool showed strong correlation with breast feeding self-efficacy, indicating that more efficient breast feeding technique is associated with increased confidence in breast feeding an infant., Conclusions: the BBAT is a concise breast feeding assessment tool facilitating accurate, rapid breast feeding appraisal, and targeting breast feeding advice to mothers acquiring early breast feeding skills or for those experiencing problems with an older infant. Accurate assessment is essential to ensure enhanced breast feeding efficiency and increased maternal self-confidence., Implications for Practice: the BBAT could be used both clinically and in research to target advice to improve breast feeding efficacy. Further research is needed to establish its wider usefulness., (Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: to explore the perceptions of primiparas on the contents, delivery and personal impact of postnatal psychoeducation programme., Design and Settings: a descriptive qualitative study was conducted in a public tertiary hospital in Singapore in 2013., Participants: 18 primiparas who were able to read and speak English were recruited from the intervention group of a randomised controlled trial., Measurements: a semi-structured interview guide was used to interview participants' perceptions on a postnatal psychoeducation programme at participants' home, which was developed based on the principles of self-efficacy and social exchange theories, between six and nine weeks post partum. The programme comprised of a 90-minute home visit, three weekly telephone follow-up and an educational booklet., Findings: the qualitative interviews revealed that the participants faced many challenges such as negative emotions and difficulties in breast feeding and support issues in the early postpartum period especially after the hospital discharge. However, all the participants in the intervention group perceived the postnatal psychoeducation programme to be helpful in increasing their confidence in newborn care, fostering help-seeking behaviour, improving emotional well-being and increasing their knowledge in newborn and self-care as well as in breast feeding. Suggestions for programme improvements included more home visits, more telephone follow-up and web-based psychoeducation as well as recommending postnatal psychoeducation programme to be offered as a routine care. Overall, there was a high satisfaction and acceptability with the programme., Conclusions: our findings indicate that the programme is beneficial for maternal well-being and confidence in maternal roles and, therefore, is promising to be introduced to the multiracial primiparas in Singapore., Implications for Practice: the challenges mothers experience during the postnatal period suggest that it would be worthwhile to devote more resources in providing follow-up support to the mothers in the early postpartum period. Midwives could incorporate a self-efficacy enhancing intervention with a family-centred approach to enable women to have a smooth transition to motherhood., (Copyright © 2014. Published by Elsevier Ltd.)

Objective: to establish how well postnatal ward neonatal hypoglycaemia guidelines facilitate breast feeding and adhere to UNICEF UK Baby Friendly Initiative (BFI) recommendations, and to compare compliance with different recommendations., Design: an appraisal of guidelines obtained via email survey using a UNICEF UK BFI checklist tool. Information about Baby Friendly Health/Hospital Initiative (BFHI) accreditation status was obtained by email questionnaire., Setting: tertiary neonatal centres in Australia and New Zealand., Participants: 22 guidelines were returned from 23 centres eligible to participate., Findings: guidelines generally scored poorly. On a scale ranging from 31 to 124 of overall guideline quality, the median score was 71. On a scale of 9 to 36 for adherence to recommendations to facilitate breast feeding, the median guideline score was 20. Compliance with the recommendation to promote skin-to-skin contact and early breast feeding was poor across all centres, achieving a score of 59 out of 88. Nine of 22 guidelines mentioned skin-to-skin contact after birth and 14 advised feeding within one hour of birth. The recommendation about discussing artificial milk supplementation with parents received a score of 44 out of 88. Fourteen guidelines listed Large for Gestational Age (LGA) infants to be at risk of hypoglycaemia. Few guidelines included up-to-date references or flowcharts., Key Conclusions: guidelines need to recommend early skin-to-skin contact and discussion with parents before artificial milk supplementation. Guidelines suggest LGA neonates are being screened unnecessarily., Implications for Practice: guidelines need constant revision as evidence for best practice expands. The UNICEF UK BFI checklist provides a readily available quality improvement tool., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Objectives: to explore first-time mothers' postnatal experiences and support needs after hospital discharge in Singapore., Design and Setting: a descriptive qualitative study was adopted in this study. Participants were recruited from a public tertiary hospital in Singapore. Semi-structured interviews were used for data collection and the interview transcripts were analysed using thematic analysis., Participants: a purposive sample of 13 English-speaking first-time mothers of age 21 years and above were interviewed within 7-11 days after their hospital discharge., Findings: five themes emerged from the thematic analysis: (1) mixed emotions: participants experienced anxiety, labile emotions and stress over infant care; (2) breast feeding concerns: low breast milk supply and physical discomfort; (3) social support: many participants had sufficient social support from family members except their husbands; (4) cultural postnatal practice: majority of participants followed traditional postnatal practices of their culture; and (5) professional support needs: participants needed more information, access to health care services and continuity of care., Conclusions: this study highlighted the importance of providing professional postnatal care to first-time mothers after their discharge from the hospital. Future studies are needed to explore new practices that will enhance the quality of maternity health care and promote positive maternal experiences and well-being in Singapore., Implications for Practice: there is a need for more innovative advertisement to promote antenatal classes and improve attendance rate. Health care providers should assist women in establishing proper breast feeding techniques. Alternative models of care in the postnatal period, such as midwifery-led care, could facilitate a more woman-centred approach. Postnatal home visits may be considered within the first week of the mothers' hospital discharge, which may be legislated by public health care policies., (© 2013 Elsevier Ltd. All rights reserved.)

Objective: to evaluate the efficacy of an intervention combining videoconferencing and telephone contact compared to standard post partum care of recent mothers attending health centres in Catalonia were recorded., Design: multicentre, randomised parallel controlled clinical trial., Participants and Setting: 1598 post partum women with Internet access attending eight 'Attention to Sexual and Reproductive Health' (Catalan acronym ASSIR) units at Primary Health Care centres, in Catalonia (Spain)., Intervention: at each of the eight ASSIR units, 100 women were randomly assigned to the intervention group (IG) and 100 to the control group (CG). Women in the IG could consult midwives by videoconference or telephone and could also receive standard care. Women in the control group received standard care from midwives at their health centres or at home., Measures: number and type of visits, reasons for consultation, type of feeding at six weeks and women's satisfaction with the intervention on a scale of 1 to 5., Findings: 1401 women were studied (80.9% of the initial sample), 683 in the IG and 718 in the CG. Two hundred and seventy-six women (40.4%) used videoconferencing or telephone in the IG. The mean total visits, virtual and face-to-face, was higher in IG women than in controls (2.74 versus 1.22). IG women made fewer visits to the health centre (mean=1) than CG women (mean=1.17). Both differences were statistically significant, with p<0.001 and p=0.002 respectively. The prevalence of breast feeding was similar in the two groups (IG 64.5%, and CG 65.4%). The mean overall satisfaction of women with midwife care was very high in both groups (IG 4.77, CG 4.76)., Conclusions and Implications for the Practice: virtual care via videoconferencing is effective for post partum women. It reduces the number of health centre visits and allows mothers to consult health staff immediately and from their own home., (© 2013 Elsevier Ltd. All rights reserved.)

Objective: the length of the postnatal hospital stay in Denmark as well as globally has been radically reduced over the past 10-20 years and this raises the challenge of finding new ways of providing observation and support to families discharged early, that they otherwise would be provided as inpatients., Aim: this study is to identify the nursing support needs of new parents and their infants during the first seven days post partum, by drawing on the experiences of all stakeholders' in early postnatal discharge from hospital, and thereby gaining new knowledge to investigate further whether telemedicine is a viable option in providing the required support., Design: this article describes the first phase of a participatory design process. A qualitative approach guided the research process and the data analysis. Data were collected from participant observation, qualitative interviews with the new parents, focus groups interviews and a workshop attended by the new parents and health-care professionals., Participants and Setting: the total number of participants in this study was 37; nineteen parents and 18 health-care professionals from one hospital and three municipalities in Denmark., Findings: the investigation findings highlighted, amongst other aspects, the importance of individualised postnatal follow-up in which families have increased access to the health-care professionals and are provided with timely information tailored to their specific needs., Key Conclusions and Implications for Practice: the present study underscored that the families experiencing early discharge were not provided with seamless individualised follow-up support. They requested more availability from the health-care system to respond to their concerns and questions during the postnatal period. They experienced a barrier in attempting to contact health-care professionals following hospital discharge and they asked for new ways to communicate that would eliminate that barrier and meet their needs for more individualised and timely information and guidance., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: to compare early discharge with home care versus standard postpartum care in terms of mothers' sense of security; contact between mother, newborn and partner; emotions towards breast feeding; and breast-feeding duration at one and three months after birth., Design: retrospective case-control study., Setting: a labour ward unit in Stockholm, Sweden handling both normal and complicated births., Participants: 96 women with single, uncomplicated pregnancies and births, and their healthy newborns., Intervention: early discharge at 12-24 hours post partum with 2-3 home visits during the first week after birth. The intervention group consisted of women who had a normal vaginal birth (n=45). This group was compared with healthy controls who received standard postnatal care at the hospital (n=51)., Instruments: mothers' sense of security was measured using the Parents' Postnatal Sense of Security Scale. Contact between mother, child and father, and emotions towards breast feeding were measured using the Alliance Scale, and breast-feeding rates at one and three months post partum were recorded., Findings: women in the intervention group reported a greater sense of security in the first postnatal week but had more negative emotions towards breast feeding compared with the control group. At three months post partum, 74% of the newborns in the intervention group were fully breast fed versus 93% in the control group (p=0.021). Contact between the mother, newborn and partner did not differ between the groups., Conclusion: early discharge with home care is a feasible option for healthy women and newborns, but randomised controlled studies are needed to investigate the effects of home care on breast-feeding rates., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objectives: to explore the emotional adjustments that women make when their baby's chronic illness or disability threatens breastfeeding., Methods: qualitative descriptive study and exploratory secondary analysis of narratives from five breastfeeding women in the UK whose babies experienced a chronic condition., Findings: three key themes were discerned: (1) 'Overwhelmed'--feelings of shock and helplessness. Engagement in the practical issues of breastfeeding, relying on others and receiving emotional support from them helped. (2) 'Under acknowledged'--women spoke of not being listened to or taken seriously. Focus on the medical condition de-valued the contribution of breastfeeding. (3) 'Striving for normality'--reframing the situation and readjusting goals and expectations helped adjustment to a 'normal' life., Discussion: varying levels of emotional adjustment were experienced by the women, and a process or path reflected their efforts to cope. Adjustments are discussed in terms of practical issues of coping and biographical disruption, thereby raising awareness of challenging aspects. Breastfeeding provided a sense of control and purpose. Understanding issues around breastfeeding an ill or disabled child can help health-care providers offer more appropriate care to women who wish to breast feed in spite of chronic illness., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objective: there is growing evidence that many parents with intellectual disabilities can parent successfully when given adequate support. This paper aims to explore the postnatal care experiences of mothers with an intellectual disability., Design: a qualitative design was used and data were collected using a semi-structured interview format and analysed using Interpretative Phenomenological Analysis., Setting: the study took place in community settings in Scotland., Participants: six mothers with intellectual disabilities were interviewed about their experiences., Measurements and Findings: two super-ordinate themes are discussed with accompanying subthemes: challenges of providing support and how support was delivered., Key Conclusions: the mothers valued formal postnatal care, but this was secondary to informal support. How mothers perceived the support impacted on its effectiveness and building effective relationships with professionals presented challenges., Implications for Practice: the study suggests the structure and quality of the wider support networks of mothers with an intellectual disability are central and should be taken account of by professionals. Providing information and advice in ways that validates the mother's role is also important, particularly as the mother's perception of how help is given can impact on the degree to which mothers engage with professionals., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Introduction: breast feeding is an essential source of nutrition among young babies; however, in Pakistan a gradual decline in prevalence of breast feeding, especially among urban working mothers, has been reported. Previous studies among Pakistani urban working mothers have revealed that ensuring exclusivity and continuation of breast feeding is challenging if social and/or workplace environmental support is minimal or absent. This problem indicated a crucial need to assess availability of breast-feeding support for Pakistani urban working mothers by using a comprehensive, reliable, and validated tool in their national language (Urdu)., Purpose: to develop and test the psychometric properties of the 'Perceived Breastfeeding Support Assessment Tool' (PBSAT) that can gauge Pakistani urban working mothers' perceptions about breast-feeding support., Methodology: this methodological research was undertaken in five phases. During phase I, a preliminary draft of the PBSAT was developed by using the Socio-ecological model, reviewing literature, and referring to two United States based tools. In Phase II, the instrument was evaluated by seven different experts, and, in Phase III, the instrument was revised, translated, and back translated. In Phase IV, the tool was pilot tested among 20 participants and then modified on the basis of statistical analysis. In Phase V, the refined instrument was tested on 200 breast-feeding working mothers recruited through purposive sampling from the government and private health-care settings in Karachi, Pakistan. Approvals were received from the Ethical Review Committees of the identified settings., Findings: the 29-item based PBSAT revealed an acceptable inter-rater reliability of 0.95, and an internal consistency reliability coefficient (Cronbach's alpha) of 0.85. A construct validity assessment through Exploratory Factor Analysis revealed that the PBSAT has two dimensions, 'workplace environmental support' (12 items; α=0.86) and 'social environmental support' (17 items; α=0.77)., Conclusion: the study developed a 29-item based two-dimensional tool (in Urdu) that has acceptable psychometric properties. The PBSAT is context specific, comprehensive, and user-friendly, so it can be administered by health-care workers, employers, policy makers, and researchers to improve the quality of services of breast-feeding urban working mothers, and could ultimately improve child health in Pakistan., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objective: to describe perceptions of participating in a study testing the effectiveness of a perinatal emotional support intervention (Promoting Resilience in Mothers Emotions; PRIME) by women identified as experiencing emotional distress after birth., Design: qualitative descriptive approach. Semi-structured telephone interviews with 33 women recruited as part of a larger RCT to test the efficacy of a counselling intervention (PRIME). Women who received either (1) the intervention (counselling (or PRIME)) (n=16), (2) active control (Parenting support) (n=12), or (3) matched control (standard care) (n=5), were interviewed at 12 months postpartum. Thematic analysis of data was used., Findings: 'promoting reflection' and 'feeling cared for', were phrases that all participants used to describe their experience in the project regardless of group allocation. Women receiving PRIME reported 'getting in touch with (their) feelings' and 'moving on' as beneficial outcomes. Two women who received counselling reported 'having things left unresolved' indicating that their needs had not been met. Some women in both the active control and intervention identified that contact was 'nice but not hugely helpful or needed'., Implications and Conclusions: positive outcomes of PRIME were evident and most participants desired postpartum contact. Some women needed additional follow up and targeted assistance. Findings support the importance of providing personalised postnatal care that addresses women's emotional health needs., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objective: women have consistently rated postnatal care less favourably than other episodes of maternity care. Midwives have also reported concerns with postnatal care, with challenges related to workloads, busy environments and lack of staff. Given these concerns, a regional hospital in Victoria, Australia redesigned its postnatal care provision. The changes included cessation of routine postnatal observations and the use of clinical pathways for women who gave birth vaginally; promotion of rest through minimal disturbances before 9 am; discouraging the use of the call bell system except in emergency situations; introduction of 'one-to-one' time with women; and promotion of normalcy and independence. This paper examines midwives' views of the changes and their impressions of the effects of the changes on women and their infants., Design: cross-sectional surveys of midwives were conducted six months after the changes to postnatal care were introduced then again, two years later. Midwives' views and experiences of the changes; the impact of the changes on confidence and autonomy of practice; views regarding the effect on women's satisfaction with care; and the perceived safety of the changes were explored., Setting: a regional hospital in Victoria, Australia where approximately 2,000 births occur each year., Participants: permanent part-time and full-time midwives., Findings: response rates were 64% (50/78) at baseline and 60% (50/84) two years later. Overall, midwives were supportive of, and complied with, the changes to postnatal care. They agreed that change was needed and believed that the new way of providing care would be better for women and increase individualised care. Midwives also agreed that the changes would facilitate rest for women, believed that removal of routine observations for women after a vaginal birth was safe and that it would allow more time with women. Over time, midwives were more likely to feel autonomous when providing postnatal care. However, some concerns were raised, mostly in relation to the challenges around postnatal documentation, care provision without the guidance of a care/clinical pathway, and about limiting the use of the call bell to only emergency situations. Midwives were not confident that the changes would necessarily translate to a measurable increase in women's satisfaction with care, and were not confident that the changes translated into more time to spend listening and providing support to women., Key Conclusions and Implications for Practice: overall, midwives were supportive of the changes and agreed that change to postnatal care was needed. Challenges remain around the most effective method of communication and documentation of postnatal care. It is important that when major changes to care provision are implemented that care providers' views and experiences are explored given their crucial role in the introduction and maintenance of changes and the potential impact on them as care providers., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objective: the aim of the study was to ascertain the attitudes of Swedish midwives towards management of very preterm labour and birth and to compare the attitudes of midwives at university hospitals with those at general hospitals., Design: this cross-sectional descriptive and comparative study used an anonymous self-administrated questionnaire for data collection. Descriptive and analytic statistics were carried out for analysis., Participants: the answers from midwives (n=259) were collected in a prospective SWEMID study., Setting: the midwives had experience of working on delivery wards in maternity units with neonatal intensive care units (NICU) in Sweden., Findings: in the management of very preterm labour and birth, midwives agreed to initiate interventions concerning steroid prophylaxis at 23 gestational weeks (GW), caesarean section for preterm labour only at 25 GW, when to give information to the neonatologist before birth at 23 GW, and when to suggest transfer to NICU at 23 GW. Midwives at university hospitals were prone to start interventions at an earlier gestational age than the midwives at general hospitals. Midwives at university hospitals seemed to be more willing to disclose information to the parents., Key Conclusions: midwives with experience of handling very preterm births at 21-28 GW develop a positive attitude to interventions at an earlier gestational age as compared to midwives without such experience., Implications for Practice: based on these results we suggest more communication and transfer of information about the advances in perinatal care and exchange of knowledge between the staff at general and university hospitals. Establishment of platforms for inter-professional discussions about ethically difficult situations in perinatal care, might benefit the management of very preterm labour and birth., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objective: to explore the views of expert midwives in Ireland and New Zealand of the skills they employ in expectant management of the third stage of labour (EMTSL)., Design: university ethical approval was granted for a qualitative descriptive study in 2010. Recorded, semi-structured interviews were undertaken. Constant comparative analysis was used., Setting: community birth settings in Ireland and New Zealand., Participants: 27 consenting midwives who used EMTSL in at least 30% of births, with PPH rates less than 4%., Findings: the majority of respondents believed the third stage was a special time of parent-baby discovery and 'watchful waiting', with no intervention necessary. Great importance was placed on women's feelings, behaviour and a calm environment. Skin-to-skin contact, breast feeding, not clamping the cord, upright positions and maternal effort, sometimes assisted by gentle cord-traction were also used., Key Conclusions: some components of EMTSL identified by these expert midwives are not recorded in text-books, but are based on experience and expertise. These elements of EMTSL add to midwifery knowledge and provide a basis for further discussion on how normal physiology can be supported during the third stage., Implications for Practice: use of these elements is recommended for women who request EMTSL, and for those in countries without ready access to uterotonics., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: homebirth for low risk women attended by competent midwives who are networked within a responsive maternity care service is supported by research as safe. Concerns exist over the safety of homebirths which are unattended by trained health professionals, or for women with medically defined risk factors. Both these birth choices are unsupported by mainstream maternity care options in Australia and therefore represent birth choices considered to be 'outside the system'., Aim: to explore the perceptions of risk held by women who choose to have a freebirth (birth at home intentionally unattended by a trained birth attendant) or a 'high-risk' homebirth (professionally attended home birth where a mother or baby has medically defined risk factors). Both of these choices are considered to be 'outside the system'., Methods: twenty women were interviewed about their choice to 'birth outside the system', nine choosing freebirth and 11 choosing to have an attended homebirth despite the presence of medically defined risk factors; three were primiparous and seventeen were multiparous. Women intending to have, or having had a freebirth or high risk homebirth, were interviewed using semi-structured interviews. Interviews were transcribed and analysed using thematic analysis., Findings: the three main themes about perceptions of risk that were evident in this study were: 'Birth always has an element of risk', 'The hospital is not the safest place to have a baby'; and 'interference is a risk'., Discussion: the participants acknowledge that birth is a time in life that carries an element of risk. They perceive that hospital represents a more risky place to give birth than at home and that interventions and interruptions during labour and birth increase risk. Women who birth outside the system perceive the risks of birth in hospital differently to most women. These women feel that by birthing outside the system they are making a choice that protects them and their babies from the risks associated with birthing in hospital and thus provides them with the best and safest birthing option., Conclusion: in pursuing the best for themselves and their babies, women who birth outside the system spent a lot of time and energy considering the risks and weighing these up. For them birth in hospital is considered less safe than birth at home., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: father's sense of security in the early postnatal period is important for the whole family. An instrument, which measures Parents' Postnatal Sense of Security (the PPSS instrument), is under development., Objective: to explore and describe factors, which influence fathers' sense of security during the first postnatal week., Methods: an explorative design with a qualitative approach was used. Thirteen fathers from three hospital uptake areas in Southern Sweden were interviewed using focus group discussions and individual interviews. Analysis was carried out using qualitative content analysis., Findings: participation in the processes of pregnancy birth and early parenthood emerged as the main category for fathers' postnatal sense of security. The emergent categories were; 'willingness to participate and take responsibility', 'being given the opportunity to take responsibility', 'being assured about mother's and baby's well-being', 'having someone to turn to-knowing who to ask', 'being met as an individual' and 'being met by competent and supporting staff'., Key Conclusions and Implications for Practice: new and specific items of importance when investigating fathers' sense of security during the early postnatal period have been pinpointed. Fathers' sense of early postnatal security may be enhanced by giving them a genuine opportunity to participate in the whole process and by giving them the opportunity to stay overnight at the hospital after the birth. Midwives and care organisations need to give clear information about where competent help and advice can be obtained at all hours. Midwives should strengthen the fathering role by acknowledging and listening to the father as an individual person., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objective: the aim of this study was to gain knowledge and a deeper understanding of the value attached by parents to relational continuity provided by midwifery students to the woman and her partner during the childbearing process. The focus of the study was on the childbirth and the postnatal home visit., Design/setting: in this pilot project by researchers at Sør-Trøndelag University College, Norway, six midwifery students provided continuity of care to 58 women throughout their pregnancy, birth and the postnatal period. One group interview of eight women and two group interviews of five men, based on the focus group technique, were conducted at the end of the project. Qualitative data were analysed through systematic text condensation., Findings: the findings included two main themes: 'trusting relationship' and 'being empowered'. The sub-themes of a 'trusting relationship' were 'relational continuity' and 'presence'. For the women, relational continuity was important throughout the childbearing process, but the men valued the continuous presence during birth most highly. 'Being empowered' had two sub-themes: 'individual care' and 'coping'. For the women, individual care and coping with birth were important factors for being empowered. The fathers highlighted the individual care as necessary to feel empowered for early parenting. The home visit of the student was highly appreciated. The relationship with the midwifery student could be concluded, and they had the opportunity to review the progression of the birth with the student who had been present during the birth. During the home visit, the focus was more on the experiences of pregnancy and birth than on what lay ahead., Key Conclusions: when midwifery students provided continuous care during pregnancy, birth and the postnatal period, both women and men experienced a trusting relationship. Relational continuity was important for women in the entire process, but for the men this was mostly important during childbirth. Individual care and coping with birth and early parenting enhanced empowerment. The limited sample size in this study means that it cannot be generalised without caution, and further research is needed., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objective: to study how Swedish midwives working in low-risk labour ward units rate intrapartum risks compared to their midwifery colleagues working in standard care labour wards. A second aim was to describe midwives' attitudes toward performing different types of interventions during a normal labour., Design: an explorative study was carried out in 2009, using a web-based questionnaire containing 31 questions on midwives' risk ratings and attitudes to interventions during labour, as well as personal comments., Setting: four labour ward units in Stockholm, Sweden. Two labour ward units with expected normal deliveries ('low-risk') and two standard care units with all types of deliveries., Participants: seventy-seven registered clinically practicing midwives., Findings: midwives in all units stated that factors to be considered for risk estimation were: previous delivery outcome, result of cardiotocography test (CTG) on admission to labour ward and quality of amniotic fluid. Midwives working at the low-risk units preferred to be more expectant during normal birth than their colleagues working at the standard care units. Examples of this were regarding second vaginal examination during labour (p=0.001) and/or amniotomy (p=0.012). Furthermore, midwives working at the low-risk units more often considered that first-time mothers could give birth without epidural analgesia during labour (p=0.019) and that the labouring woman should be encouraged to push according to her own spontaneous urge (p=0.040). Midwives at low-risk units were more reluctant to use an intravenous vein catheter than their colleagues at standard care units (p=0.001) and also to use oxytocin in order to augment contractions (p=0.013). Further, the open-ended question showed that attitudes to different types of interventions differed between midwives working at low-risk units or the standard care units working with all types of deliveries., Conclusion: the Swedish midwives estimated risks similarly regardless of whether they worked in low-risk or in standard care units, but midwives working at low-risk units reported that they perform less routine interventions and have a more expectant attitude towards performing interventions., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: In Sweden pregnant women are encouraged to remain at home until the active phase of labour. Recommendation is based on evidence, that women who seek care and are admitted in the latent phase of labour are subjected to more obstetric interventions and suffer more complications than women who remain at home until the active phase of labour. The aim of this study was to obtain a deeper understanding of how women, who remain at home until the active phase of labour, experience the period from labour onset until admission to labour ward., Method: Interviews were conducted with 19 women after they had given birth to their first child. A Constructivist Grounded theory method was used., Findings: 'Maintaining power' was identified as the core category, explaining the women's experience of having enough power, when the labour started. Four related categories: 'to share the experience with another', 'to listen to the rhythm of the body', 'to distract oneself' and 'to be encased in a glass vessel', explained how the women coped and thereby maintained power., Conclusions: The first time mothers in this study, who managed to stay at home during the latent phase of labour, had a sense of power that was expressed as a driving force towards the birth, a bodily and mental strength and the right to decide over their own bodies. This implies that women who maintain power have the ability to make choices during the birth process. The professionals need to be sensitive, supportive and respectful to women's own preferences in the health-care encounter, to promote the existing power throughout the birthing process., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Objective: To explore the challenges of conducting an observational study of postnatal interactions, between midwives and women, when the researcher was a midwife observing in familiar midwifery settings., Background: Participant observation conducted by researchers who are themselves midwives raises questions regarding the influence of 'identity' and 'insider' knowledge on the conduct of such projects. The insider/outsider status of researchers has been explored in other disciplines, yet this is an area which is underdeveloped in the midwifery literature where few attempts have been made to subject this issue to sustained analysis., Design: A qualitative study (investigating the provision of breast-feeding support in the first week after birth) provided the opportunity for reflexive exploration of the tensions faced by midwife researchers., Setting: Two maternity units in New South Wales, Australia., Participants: Participants included 40 midwives and 78 breast-feeding women., Findings: Possessing 'insider' midwifery knowledge was advantageous in the 'getting in' and 'fitting in' phases of this research study however unanticipated role ambiguity, and moral and ethical challenges, arose as a result of this 'insider' knowledge and status. Prolonged periods of observation challenged the midwife researcher's preconceived ideas and early decisions about the advantages and disadvantages of being an 'insider' or an 'outsider' in the research setting., Key Conclusions: Reflexive analysis of insider/outsider experiences revealed the middle ground which participant observers tend to navigate. Whilst professional insider knowledge and status offered many advantages, especially at the first study setting, some of the inherent embodied, and socially constructed features of the 'midwife' observer role, were unanticipated. Cultural competence, in these observational study settings, translated into role ambiguity, and at times, culturally entrenched role expectations., Implications for Practice: Midwifery observation of clinical practice, for research, or practice development purposes, requires a degree of juggling of insider knowledge to facilitate observation and analysis. Prior to conducting observations midwives should consider how best to occupy the middle ground between insider and outsider. Within the middle ground the midwife can draw on those aspects of 'self' required to negotiate respectful relationships with colleagues, whilst also ensuring the maintenance of an analytical degree of distancing., (Copyright © 2010 Elsevier Ltd. All rights reserved.)