At the turn of the twentieth century maternal mortality was extremely high, with one in every two hundred women dying as a consequence of childbirth, the main causes of death being puerperal sepsis and haemorrhage. The impact of pregnancy and childbirth on the lives and health of working women is beautifully illustrated in letters first published in 1915, many written by women prevented from seeking advice or assistance because of prevailing views of modesty and the expected behaviour of ‘respectable’ women (Llewelyn Davies 1977). The maternal mortality rate continued to be high, despite a fall in death rates from all diseases in the general population from around 1870 onwards. This dramatic reduction was not solely a consequence of improvements in medicine, but resulted from improvements in social and sanitary conditions that led to fewer people dying from infectious disease. Ironically, maternal mortality was often higher amongst middle-class women, whose families were most likely to pay for medical rather than the less expensive midwifery care. Despite concerns over maternal mortality, midwifery care was not freely available to all women until 1936. This was a period during which there was increased professional rivalry between general practitioners and midwives, with the British Medical Association opposing the report of the Joint Committee of Midwives that there should be free access to midwifery care. Despite the opposition, the incentive to pass legislation to integrate midwives in private practice within public maternity services culminated in the passing of the 1936 Midwives Act. Changes to social services, welfare benefits and the health service during and after the Second World War contributed to a sudden and dramatic decline in maternal mortality, alongside advances in antibiotic therapy, drugs to control haemorrhage, increased availability of blood transfusion services and the establishment of obstetric flying squads. In 1943, the death rate fell to 2.3 deaths per 1,000 registered births. The most recent triennial Confidential Enquiry into Maternal Death which covered all deaths occurring between 1997 and 1999 found a maternal mortality rate of 11.4 deaths per 100,000 maternities, including both direct and indirect deaths (Lewis & Drife 2001). The content of each postnatal visit followed a ritualistic pattern, with set timings for the completion of each observation and examination and strict protocols for hand washing (Leap & Hunter 1993), such was the great fear of infection. Midwives were expected to undertake daily observations of a woman’s temperature, pulse, blood pressure and assess uterine involution (to ensure the uterus is returning to a pelvic organ) and vaginal blood loss (the lochia). The woman’s legs were also to be examined for the possible occurrence of deep vein thrombosis (DVT), although confining women to bed for 10 days probably increased the risk of DVT. Although intrapartum care gradually transferred from the home to the hospital, community-based postnatal care has continued to adhere to a very traditional pattern in both content and duration. The only changes include reduced in-patient stay after delivery and the dropping in 1986 of the specification that a midwife had to make twice daily home visits for the first 3 days, followed by daily visits until day 10, in favour of a policy of ‘selective’ home visiting (UKCC 1992). The policy of selective visiting was introduced with no evidence to support or facilitate the alteration to practice, and no guidance on how to determine the number and frequency of visits appropriate to meet individual postnatal needs. Thus, postnatal care provision has remained largely unaltered during the century since its inception, with no guidance on how care could be tailored to meet need and, until recently, little evidence of whether the provision of care benefited women’s physical and psychological health (Marchant & Garcia 1995, MacArthur et al 2002). The most recently issued Nursing and Midwifery Council rules state only that midwives should ‘care for and monitor the progress of the mother in the postnatal period and give all necessary advice to the mother on infant care to enable her to ensure the optimum progress of the new-born infant’. In relation to the duration of postnatal care provision by midwives, the NMC defines the postnatal period as a ‘period of not less than 10 and not more than 28 days after the end of labour, during which the continued attendance of a midwife on the mother is requisite’. There are currently no plans to revise the rules with regard to postnatal care. The midwifery contribution to the public health agenda during the postnatal period can include support for nationally and/or locally agreed priorities to reduce health inequalities. For example, smoking cessation and reduction in teenage pregnancy were two areas highlighted in the first national health inequalities targets (DH 2001). Postnatal care can also address other areas known to enhance short- and long-term health of the public, such as promotion and support for breastfeeding, advice on infant immunisation, nutrition, health promotion, and provision of information on screening. Midwives can also contribute to government programmes to assist women and their families in targeted areas of deprivation, for example through Sure Start projects and involvement with local health needs assessment initiatives. These are all important public health initiatives, but ways in which appropriate and timely care can be targeted to those with the greatest need have to be considered against the need to provide a statutory midwifery service to all women after childbirth. Until recently, becoming pregnant during the teenage years was viewed as normal and even desirable; physiologically, giving birth at 18 or 19 may be better than commencing childbearing later in life, which is the current trend in the UK and other developed countries. Concerns from a public health perspective relate in the main to the inequalities in health and socio-economic status faced by teenage women and their infants. Teenage pregnancy is almost ten times higher for a woman whose family is in social class V than those in social class I, and infant mortality for babies of teenage mothers is 60% higher than for infants born to older women. There is debate as to whether a higher frequency of adverse perinatal outcome among first teenage pregnancies is an independent association, or explained by confounding factors such as socio-economic class and maternal smoking (Berenson et al 1997, Olaussson et al 1999). A recent retrospective cohort study from Scotland found that second births to non-smoking teenage mothers aged 15-19 were associated with an almost threefold risk of pre-term delivery and stillbirth (Smith & Pell 2001). The achievement of a reduction in the teenage pregnancy rate in the UK, as described in Chapter 9, will clearly involve contributions from a range of health, education and social support agencies. The postnatal role of the midwife caring for a teenage mother can be targeted across a range of activities within this remit, as well as in relation to other areas, to enhance maternal and infant health. For example, midwives should advise on infant care and support for breastfeeding (described later in this chapter), facilitate access to social support, and identify and manage postnatal morbidity. Care provision could also include advice on sexual health problems, including protection against future unwanted pregnancy and sexually transmitted diseases (STDs). Traditionally, midwifery postnatal care has included provision of advice on contraception, although guidance for midwives is limited and there is a dearth of information on the benefit of any advice thus given and optimal timing of it. Nevertheless, midwives should ensure teenage women they care for are asked about their contraceptive needs as soon as appropriate after the birth, especially as it is now apparent that over a third of women may have resumed intercourse within 6 weeks of giving birth (Sleep et al 1984, Klein et al 1994, Barrett et al 2000). It has been well documented that use of contraception by young people is inconsistent (Ingham et al 2001), and improvement of access to contraceptive services is seen as key to the government’s strategy to reduce the rate of conceptions among the under-18s (DH 2000a). The Teenage Pregnancy Unit, which is based in the Department of Health and co-ordinates implementation of the Teenage Pregnancy Strategy in England, has issued Best Practice Guidance on the provision of effective contraception and advice services for young people (DH 2000a). These include the need to involve young people in the planning of services, ensuring confidentiality is maintained and any advice is non-judgemental. Teenagers who do not wish to have another pregnancy in the near future should be advised of the need to recommence contraception within at least 21 days of the birth, when ovulation may recommence. Referral to the GP or Family Planning Clinic should be made for those who may wish to commence oral contraception, or if they wish to discuss other options for contraception. Consideration when providing advice on a request for contraception made by someone under 16 has to be given within the current legal framework, and midwives should ensure they are familiar with this. If midwives require advice on action to co-ordinate the Teenage Pregnancy Strategy in their locality, each local authority has a teenage pregnancy co-ordinator. Twenty Sure Start Plus pilot projects are also underway, which provide support for pregnant teenagers and teenage parents on a variety of health, social and childcare issues. A recent Australian trial aimed to ascertain if a postnatal home visiting service for teenagers under 18, the content of which was structured to particular needs of this group, could reduce the frequency of adverse neonatal outcomes and improve knowledge of contraception, infant vaccination schedules and breastfeeding (Quinlivan et al 2003). Of the young women who attended a teenage pregnancy clinic, 139 were entered into the trial antenatally and 136 allocated immediately after delivery to receive either five structured postnatal home visits by nurse-midwives in addition to routine postnatal care (n = 71), or usual care (n = 65). Three women were withdrawn before randomisation because of late fetal loss. All teenagers were asked to complete an antenatal questionnaire designed to assess their knowledge of the health areas described above. The questionnaires were completed with the assistance of a midwife, their unprompted answers being recorded verbatim. Level of knowledge was scored later by a member of the research team who was unaware of the teenager’s identity or group allocation. For contraception the total score achievable was 9; for infant vaccination it was 10; and for benefits of breastfeeding the maximum available overall score was 11. Those in the intervention group received structured home visits at 1 week, 2 weeks, 1 month, 2 and 4 months after the birth, with visits lasting for 1-4 hours. Each visit was to include advice related to a specific health area for the teenager and her infant, appropriate to expected recovery and development and relevant to service provision at that point in time, as well as ensuring screening and other social issues were addressed. Information to support why five postnatal visits were provided was not presented. The primary trial outcomes were knowledge in the health areas of interest and incidence of predefined adverse neonatal outcome. At 6 months post partum, a postnatal assessment visit was undertaken during which a questionnaire identical to that administered antenatally was completed and scored. In addition, the teenagers were asked about use of contraception, compliance with infant vaccination schedules and duration of breastfeeding. Contraception and sexual health should not be discussed in isolation from resumption of intercourse. Research into women’s experiences of sexual health problems after delivery is limited, with information on prevalence arising from observational studies and trials of perineal management. Data that are available are therefore only applicable to groups of particular parity or mode of delivery. Brown and Lumley (1998) contacted 1336 women 6-7 months post partum in a cross-sectional study of all deliveries occurring over a 2-week period in one region in Australia, and found 26% had experienced a ‘sexual problem’ some time since their delivery. No information on the specification or duration of the problem was elicited. Barrett et al (2000) conducted a cross-sectional study of all primiparous women who delivered at one maternity unit in London, to enquire about a range of sexual health problems. Postal questionnaires were sent at 6 months post partum to 796 primiparae, asking about sexual health problems since the birth and prior to pregnancy; 484 (61%) women replied. Women were asked to recall when they had first resumed intercourse; by 6 weeks 32% had resumed intercourse, 62% had done so by 8 weeks and 81% by 3 months. The researchers asked women about experiences of dyspareunia, which they described as including painful penetration and/or pain during intercourse or orgasm. This was reported by 62% of women at some time during the first 3 months after the birth, and still experienced by 31% at 6 months post partum. Other sexual health problems included loss of sexual desire, reported by 53% in the first 3 months and 37% at 6 months. Several other problems were also reported at 6 months, including vaginal tightness (20%), vaginal looseness or lack of muscle tone (12%) and lack of vaginal lubrication (26%). Although only two thirds of women returned a questionnaire, these data do highlight that sexual health problems after childbirth are common and persistent. The importance of the midwife asking teenage mothers about sexual health problems is highlighted as they may have one or more risk factors for dyspareunia. These have been identified as mode of delivery, perineal trauma and primiparity, which are all highly interrelated and likely to be variables that include higher proportions of younger women. Higher rates of perineal pain have been reported after instrumental delivery. Glazener et al (1995), in a representative sample of all deliveries over a defined period, found 42% reported perineal pain when questioned in hospital, 22% reported experiencing this between then and 8 weeks post partum; and when questioned again at 12-18 months post partum, 9.8% had experienced perineal pain at some time between 8 weeks and 12-18 months. Differences in perineal pain were clearly related to mode of delivery. Prevalence of pain whilst still in hospital was 84% after instrumental delivery, 42% after a spontaneous vaginal delivery and 5% after caesarean section. Barrett et al (2000) in the study described earlier found that dyspareunia occurring some time during the 3 months after delivery was reported by 62% of women following spontaneous vaginal delivery, 78% after instrumental delivery (forceps or ventouse), 41% after an emergency caesarean section and 47% following elective caesarean section. Logistic regression showed that the difference for instrumental relative to spontaneous vaginal delivery remained significant (OR 2.41, 95% CI 1.24-4.69), but differences for both types of caesarean section did not. Evidence to support the most effective interventions to relieve dyspareunia is limited, as many studies have only examined experience of pain. One Cochrane Review of the use of therapeutic ultrasound to treat acute and persistent perineal pain and dyspareunia following childbirth, which included four trials involving 659 women, concluded that there was insufficient evidence to evaluate benefit (Hay-Smith 2004). One way midwives could help is to advise women who have had perineal trauma that resumption of intercourse may be painful, which may provide some reassurance, and ensure that referral is made to their GP if pain persists. Many teenage mothers will have specific health and social support needs, as well as needs which are as relevant for all new mothers. There is limited guidance on optimal organisation and content of services in the UK for teenage parents, including specific interventions to reduce future unplanned pregnancies (DH 2000a), and although the trial by Quinlivan and colleagues (2003) suggests tailored interventions to very young mothers may increase awareness of contraception and improve outcomes for their babies, it would have to be replicated in a UK population. It is important that midwives discuss contraception and sexual health, and ensure teenage mothers have every opportunity to state what they want from postnatal care, rather than providing care based on their own perceptions of the needs of the teenager. Other public health initiatives relevant to the health and well-being of teenage mothers and their infants, such as smoking cessation and uptake and prevention of early cessation of breastfeeding, are discussed later in this chapter. There is a strong association between smoking and socio-economic status, with higher proportions of regular smokers found amongst people in lower socio-economic groups. It is the biggest cause of preventable death in the western world, killing more than 120,000 people in the UK each year (Health Development Agency 2003). Over half (54%) of babies and young children from lower socio-economic backgrounds are exposed to ‘passive smoking’ or environmental tobacco smoke (ETS), compared to 18% of those from higher socio-economic backgrounds (Health Development Agency 2003). The current Government’s national target is a reduction from 23% to 15% in the proportion of women who smoke during pregnancy by 2010 (DH 2001). Smoking during pregnancy can contribute to potentially adverse effects on the health of the woman and the fetus. It is one of the few potentially preventable factors associated with low infant birth weight (< 2.5 kg), premature birth and perinatal death (Lumley et al 2004). Smoking has also been strongly associated with elevated risk of placenta praevia, abruptio placentae, ectopic pregnancy and premature rupture of the membranes (Castles et al 1999). Infant exposure to ETS has been associated with development of other adverse events including serious respiratory illness and asthma attacks, sudden infant death syndrome (SIDS) and middle ear disease (Blair et al 1996).
Postnatal care: meeting the public health challenge
POSTNATAL CARE PROVISION BY MIDWIVES
HISTORICAL PERSPECTIVE
POSTNATAL CARE AND PUBLIC HEALTH PRIORITIES
TEENAGE MOTHERS
SMOKING
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Postnatal care: meeting the public health challenge
