134What are the models for delivering the care?

Grading:1++High-quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias
RID: 694Reference number 4787
Hodnett ED;
Continuity of caregivers for care during pregnancy and childbirth
1998Ltd
Chiche
pgs
Study Type:Systematic Review
Patient
Characteristics
Intervention
Comparisons
Study Length
Outcomes
Effect
FundingCochrane
ConclusionsThis is a review of two studies involving 1815 women. Both trials compared continuity of care by midwives with non continuity of care by a combination of physicians and midwives. Women with continuity of care were more likely to feel able to discuss postpartum problems and more likely to feel prepared for child care. The reviewers conclude that The two studies show beneficial effects of continuity of care overall.
Quality++
Grading:1+Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
RID: 665Reference number 4351
Brown S;Small R;Faber B;Krastev A;Davis P;
Early postnatal discharge from hospital for healthy mothers and term infants
2004Issue 3The Cochrane Librarypgs
Study Type:Systematic Review
Patient
Characteristics
Intervention
Comparisons
Study Length
Outcomes
Effect
FundingCochrane
ConclusionsThis review reported inconclusive findings. There is no evidence of adverse outcomes associated with policies of early postnatal discharge but this possibility cannot be ruled out.
Quality+A pooled estimate from six trials on breastfeeding outcomes was calculated despite significant heterogeneity. The rationale was that all studies compared early discharge with standard care.
RID: 684Reference number 4776
Ciliska D;Mastrilli P;Ploeg J;Hayward S;Brunton G;Underwood J;PHRED Program;
The effectiveness of home visiting as a delivery strategy for public health nursing interventions to clients in prenatal and postnatal period: a systematic review
1999PHRED Program, Public Health Branch Ontario Ministry of Healthpgs
Study Type:Systematic Review
Patient
Characteristics
Intervention
Comparisons
Study Length
Outcomes
Effect
FundingOntario Public Health Research
ConclusionsThere were no reported negative effects of home visiting. Positive outcomes included improvement in children’s mental development, mental health and physical growth, reduction in mother’s depression, improvement in maternal employment, education, nutrition and other health habits. No proven impact on low birth weight, gestational age or neonatal morbidity or
Quality+Non randomised studies included in review. Review also included studies of premature infants and high risk women
RID: 718Reference number 4812
Escobar GJ;Braveman P;
Home visits vs. hospital-based group follow-up visits after early postpartum discharge
200149: (4)Pediatric Researchpgs 196A
Study Type:Randomised Controlled Trial
Patientpp women whose discharge was anticipated on the day of recruitment at Kaiser Foundation Hospital
Characteristic
InterventionGroup pp visits v. home visits
ComparisonsWith one exception (maternal urgent care visits - p<0.01) the clinical outcomes for mothers and babies did not differ between groups. Mothers in the home visit group were more satisfied with care (p<0.01)
Study Length2 weeks
OutcomesChi square and p values
EffectNS difference on clinical outcomes. Maternal satisfaction in home visit group significant,
FundingKaiser Permanente
ConclusionsThe authors found that group postnatal visits and home visits achieved equivalent clinical outcomes. However, group visits had far lower costs, whereas home visits had markedly higher maternal satisfaction.
Quality+Satisfaction surveys subject to potential bias
RID: 672Reference number 4750
Grullon KE;Grimes DA;
The safety of early postpartum discharge: a review and critique
199790: (5)Obstetrics and Gynecologypgs 860 865
Study Type:Systematic Review
Patient
Characteristics
Intervention
Comparisons
Study Length
Outcomes
Effect
FundingUnknown
ConclusionsThe reviewers concluded that the current data do not support or condemn widespread use of early postpartum discharge in the general population. Early pp discharge appears safe for carefully selected, consenting women.
Quality+This review was medline only
RID: 662Reference number 2368
Gunn J;Southern D;Chondros P;Thomson P;Robertson K;
Does an early postnatal check-up improve maternal health: results from a randomised trial in Australian general practice
1998105:British Journal of Obstetrics & Gynaecologypgs 991 997
Study Type:Randomised Controlled Trial
PatientPP women with full term live birth and healthy baby
Characteristics
InterventionWomen were randomised to a GP visit one week after discharge versus a six week checkup
ComparisonsBreastfeeding rates; depression; maternal health; communication with provider and content of exam
Study Length6 months
OutcomesORs
EffectWomen in the intervention group were less likely to have a vaginal exam (OR 0.51, 0.34–0.77)or pap smear(OR0.34, 0.22–0.52) and more likely to talk to the GP about their baby (p=0.02) and about labour and birth (OR1.77, 1.17–2.68). There were NS differences on any major health outcomes studied.
FundingVictorian Health Promotion Foundation, Royal Australian College of General Practitioners
ConclusionsThe authors suggest that a shift in focus might occur from a routine vaginal examination to an opportunity to spend time talking with a GP.
Quality+This is a survey using self reported questionnaire.
RID: 693Reference number 4785
Hicks C;Spurgeon P;Barwell F;
Changing Childbirth: a pilot project
200342: (6)Journal of Advanced Nursingpgs 617 628
Study Type:Randomised Controlled Trial
PatientPregnant women booking at a local trust
Characteristics
InterventionTeam midwifery v. traditional care
ComparisonsSatisfaction with various aspects of pp care
Study Length6 weeks
OutcomesChi square and p values
EffectNS differences on clinical outcomes;the continuity of care group had statistically significant greater satisfaction with care at home following birth. However, overall satisfaction levels for both groups were high, indicating that while the traditional care group might have been less satisfied their absolute satisfactions levels were still high.
FundingUnknown
ConclusionsThis study adapted the concept of continuity of carer to continuity of care and concludes that this study supports the possibility of using team midwifery to provide care in the spirit of Changing Childbirth.
Quality+Questionnaires are subject to bias as the responses are subjective and voluntary
RID: 668Reference number 4681
Lieu TA;Braveman PA;Escobar GJ;Fischer AF;Jensvold NG;Capra AM;
Randomized comparison of home and clinic follow-up visits after early postpartum hospital discharge
2000105 (5)Paediatricspgs 1058 1065
Study Type:Randomised Controlled Trial
PatientPP women about to be discharged from Kaiser Foundation Hospital in Sacrament, California
Characteristics
InterventionOne home visit v. one paediatric clinic visit
ComparisonsRehospitalization, emergency visits and urgent clinic visits, breastfeeding discontinuation and maternal satisfaction
Study Length2 weeks
OutcomesRR
EffectNS differences on clinical parameters. Mothers in the home visit group were more satisfied with all aspects of care (p<0.001)
FundingInnovation Program of Kaiser Permanente
ConclusionsThis study indicates that maternal satisfaction is higher for a home visiting program than a clinic based program.
Quality+Telephone interviews may have introduced bias
RID: 651Reference number 612
MacArthur C;Winter HR;Bick DE;Lilford RJ;Lancashire RJ;Knowles H;Braunholtz DA;Henderson C;Belfield C;Gee
Redesigning postnatal care: a randomised controlled trial of protocol-based midwifery-led care focused on individual women’s physical and psychological health needs. [102 refs]
20037: 37Health Technology Assessmentpgs 1 98
Study Type:Randomised Controlled Trial
PatientThere were no significant differences between the women but there were some proportionate differences. In the main intervention group there was a higher proportion of women at risk for poor health outcomes.
Characteristics
InterventionMidwifery lead carefor 28 days pp using a symptom checklist and the EPDS for screen for pp depression.
ComparisonsPhysical and psychological health at 4 and 12 months and satisfaction with care.
Study Length12 months
OutcomesChi square and p values
EffectNS difference on physical health scores. The EPDS and MCS scores were significantly better in the intervention group (p<0.0003)
FundingHTA
ConclusionsThese researchers concluded that the redesigned community postnatal care led by midwives and delivered over a longer period resulted in an improvement in women’s mental health at 4 months pp which persisted at 12 months. The data do not provide evidence for the cause of improved psychological well being in this model.
Quality+Use of SF 36 in pp women not validated; use of EPDS scores as an outcome may not be a valid use of the scale. However, the EPDS may be used as a screening tool in research among pp women >28 days post delivery. Diaries kept by women may be biased.
RID: 674Reference number 4754
Margolis LH;
A critical review of studies of newborn discharge timing
199534: (12)Clin Pediatr (Phila)pgs 626 634
Study Type:Systematic Review
Patient
Characteristics
Intervention
Comparisons
Study Length
Outcomes
Effect
FundingCDC and Maternal and Child Health Bureau
ConclusionsAll 13 studies reviewed suggest that there are no differences between infants discharged early and those receiving standard care. However the studies have methodological flaws and require careful interpretation.
Quality+Medline only
RID: 702Reference number 4796
Morrell CJ;Spiby H;Stewart P;Walters S;Morgan A;
Costs and benefits of community postnatal support workers: a randomised controlled trial
20004: (6)Health Technology Assessmentpgs
Study Type:Randomised Controlled Trial
PatientPostnatal women in Sheffield who delivered a live baby
Characteristics
InterventionSupport workers and midwifery care v. usual midwifery care
ComparisonsPhysical and mental health and social support
Study Length6 months
OutcomesSF-36, EPDS, DUFSS, and EQ-5D
EffectControl group significantly better physical and social functioning (p<0.01 and p<0.03). No other significant differences on primary clinical outcomes
FundingHTA
ConclusionsIt appears that from a clinical standpoint the use of support workers is not effective in improving mother’s health.
Quality+Survey response are subjective and involve a self selected population and may be biased
RID: 647Reference number 300
Reid M;
A two-centred pragmatic randomised controlled trial of two interventions of postnatal support
2002109: (10)BJOG: an International Journal of Obstetrics & Gynaecologypgs 1164 1170
Study Type:Randomised Controlled Trial
PatientPrimiparous women who attended antenatal clinics between 34 and 37 weeks of pregnancy
Characteristics
InterventionUse of manual v. support group for additional support in pp time period
ComparisonsEPDS scores, SF-36 scores for physical and mental health; SSQ6 scores for social support
Study Length6 months
OutcomesChi square and p values
EffectNS differences on any of the outcome measures
FundingScottish Office
ConclusionsThis study indicates that wide scale provision of support groups or self help manuals is not appropriate if the aim is to improve measurable health outcomes
Quality+This study used the SF 36 for physical and mental health assessment - not validated for pp women. Maternal responses subject to potential bias
RID: 641Reference number 9
Steel O’Connor KO;Mowat DL;Scott HM;Carr PA;Dorland JL;Young Tai KF;
A randomized trial of two public health nurse follow-up programs after early obstetrical discharge: an examination of breastfeeding rates, maternal confidence and utilization and costs of health services
200394: (2)Canadian Journal of Public Healthpgs 98 103
Study Type:Randomised Controlled Trial
PatientWomen delivering infants at two tertiary care hospitals in southeastern Ontario. All mothers were primiparours, and delivered a single infant vaginally.
Characteristic
InterventionHome visit v. telephone screening pp
ComparisonsMaternal confidence, infant health and breastfeeding
Study Length6 months
OutcomesORs and p values
EffectNS difference in maternal confidence, infant health and breastfeeding. See economic analysis
FundingThe Physicians’ Services Incorporated Foundation
ConclusionsThis study concludes that although universal access to pp support is important, the results suggest that a routine home visit is not always necessary to identify the women who need it.
Quality+Validity of maternal confidence scale not provided;all other information by maternal report which has potential for bias.
RID: 712Reference number 4806
Turnbull D;Holmes A;Shields N;Cheyne H;Twaddle S;Gilmour WH;McGinley M;Reid M;Johnstone I;Geer I;McIlwaine G;Lunan CB;
Randomised, controlled trial of efficacy of midwife-managed care.
1996348: 9022Lancetpgs 213 218
Study Type:Randomised Controlled Trial
PatientPregnant women with no adverse characteristics attending the Glasgow Royal Maternity
Characteristics
InterventionShared care v. midwifery managed care
ComparisonsMaternal satisfaction with hospital and home postnatal care
Study Length7 weeks pp
OutcomesChi square and p values
EffectSatisfaction with hospital pp care p<0.00001 in midwifery group. Women in the midwife managed group also resported greater satisfaction with choice(p<0.0006), information (p<0.03), decision making(p<0.007) and individualised care(p<0.02).
FundingScottish Office Home and Health Department
ConclusionsThe conclusion of the researchers was that midwife managed care for healthy women integrated within existing services is clinically efficacious.
Quality+Clinical information was complete for 97.5% and 99.2% of women in the study. But lower response rates for the questionnaire and the subjective nature of the investigation may bias results
RID: 649Reference number 556
Waldenstrom U;
Early and late discharge after hospital birth: Fatigue and emotional reactions in the postpartum period
19888: (2)Journal of Psychosomatic Obstetrics & Gynecologypgs 127 135
Study Type:Randomised Controlled Trial
PatientPostpartum women in a Swedish clinic, with uncomplicated vaginal delivery
Characteristics
InterventionEarly discharge (24–48 hours) and normal hospital care
ComparisonsLevels of fatigue by diary; baby blues by tearfulness; and depression by questionnaire report
Study Length42 days
OutcomesChi square, p values
EffectNS difference in fatigue, baby blues and depressed mood. In both groups women were most tired during the first days after hospital discharge.
FundingSwedish Minisry of Health and Social Affairs
Conclusions
QualityThe high dropout rate, particularly in the experimental group was a potential bias in this study. The results are also a subjective evaluation
RID: 717Reference number 4811
Wiggins M;Oakley A;Roberts I;Turner H;Rajan L;Austerberry H;
The Social Support and Family Health Study: a randomised controlled trial and economic evaluation of two alternative forms of postnatal support for mothers living in disadvantaged inner-city areas
20048: 32Health Technology Assessmentpgs
Study Type:Randomised Controlled Trial
PatientWomen who had given birth between 1 January 1999 and 30 September and were resident in the deprived districts of Camden and Islington.
Characteristic
InterventionSocial support via home support visitors, community groups or usual care
ComparisonsChild injury, maternal smoking, maternal depression, health service usage, maternal and child health, infant feeding and experience of motherhood
Study Length18 months
OutcomesRR and mean difference, p values
EffectNS differences on the primary outcomes of maternal depression, child injury or maternal smoking. Uptake of community group support intervention was low: 19% compared with 94%. Over half of the women in the home support visitor group found them to be very helpful.
FundingHTA
ConclusionsThere was no evidence of impact on the primary outcomes of either intervention. The home support visitors were popular with women.
Quality+Maternal self report and the EPDS used at baseline may introduce bias
Grading:1−Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias*
RID: 707Reference number 4801
Shields N;Reid M;Cheyne H;Holmes A;McGinley M;Turnbull D;Smith LN;
Impact of midwife-managed care in the postnatal period: An exploration of psychosocial outcomes
199715 2Journal of Reproductive & Infant Psychologypgs 91 108
Study Type:Randomised Controlled Trial
PatientAntenatal women who booked within 16 weeks of pregnancy and had no known medical or obstetric complications
Characteristic
InterventionThis is a comparison of care by the same midwife in hospsital and at home versus care by two different sets of midwives in hospital and at home
ComparisonsWomen rated structure of postnatal care, preparation for parenthood, postnatal depression and infant feeding.
Study Length7 week postnatal questionnaire
OutcomesChi square trends
EffectWomen in the intervention group rated their care more highly in relation to : structure of care (p<0.00001); preparation for parenthood (p<0.00001) and advice about infant feeding (p<).00001). They were also less likely to be depressed based on responses to EPDS (p=0.01)
FundingScottish Home and Health Department
ConclusionsThis study suggests that continuity of care has the potential to confer some psychosocial benefit to women but the results herein must be interpreted with caution due to poor response rate and subjectivity of responses.
QualityThe response rate was low and the questionnaire subjective. EPDS not validated as a 9 item scale but mean scores were compared.
Grading:2+Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance
RID: 700Reference number 4794
McCourt C;Page L;Hewison J;Vail A;
Evaluation of one-to-one midwifery: women’s responses to care
199825: (2)Birthpgs 73 80
Study Type:Cohort
PatientPregnant women in the study areas were referred to one to one care. There were differences in the populations which comprised study groups and control groups. The study group had more social risk factors.
Characteristics
InterventionStyle of midwifery care
ComparisonsWomen who received one to one care and women who received conventional care were evaluated on satisfaction with care including home and hospital pp care, preparation for parenthood and preference for continuity of care.
Study Length13 weeks pp
OutcomesFrequency percents
EffectPostpartum hospital care: 50% of study group v. 54% of control group ’very satisfied’ NS differences in postpartum physical symptoms (no stats given). Postnatal depression scores were similar(no stats given).
FundingKing’s Fund and core grants to the Centre for Midwifery Practice
ConclusionsThe evaluation of one to one midwifery care wasncompared to conventional care. Although women appeared to be satisfied with care there were no significant statistical differences in satisfaction or in physical or psychological symptoms. The population samples differed on several socioeconomic factors and it is unclear whether these were controlled for in the analysis. The sample was not randomised and there was a relatively low response rate to
Quality+This survey involves obtaining subjective responses from a self selected group. The inherent bias in this methodology may affect outcomes.
Grading:2Case–control or cohort studies with a high risk of confounding bias, or chance and a significant
RID: 687Reference number 4779
Farquhar M;Camilleri C;Todd C;
Continuity of care in maternity services; women’s views of one team midwifery scheme
200016: (1)Midwiferypgs 35 47
Study Type:Cohort
PatientPostpartum women in southeast England
Characteristics
InterventionMidwifery teams versus standard care
ComparisonsMaternal satisfaction with pp care in hospital and at home in each group
Study LengthOne time questionnaire after six weeks pp
OutcomesSatisfaction and continuity of carer
EffectNS differences in satisfaction for postpartum care in hospital and at home; the study group reported the lowest continuity of carer(care from just one or two midwives) both antenatally and postnatally: 22 % compared to 82% and 52% in the comparison groups.
FundingNorth Thames Regional Health Authority and North Essex Health Authority
ConclusionsThe authors conclude that midwifery teams of seven midwives may be too large. The focus on continuity through antepartum, intrapartum and postpartum may be misguided and that the focus might better be focused on the antenatal and postnatal periods.
QualityAdjustment for confounding not described despite known differences between groups. The return of questionnaires is a self selected process and answers arfe subjective
RID: 710Reference number 4804
Spurgeon P;Hicks C;Barwell F;
Antenatal, delivery and postnatal comparisons of maternal satisfaction with two pilot Changing Childbirth schemes compared with a traditional model of care
200117: (2)Midwiferypgs 123 132
Study Type:Cohort
PatientPregnant women randomly drawn from GP practices in the sponsoring Trust
Characteristics
InterventionModels of service delivery
ComparisonsSatisfaction; clinical outcomes; number of days in hospital and number of home visits; information and advice
Study Length6 weeks
OutcomesChi square; p values
EffectNS difference in length of stay; Significat differences on number of home visits there being fewer for Group C (p<0.001). Groups A and B were significantly more satisfied on all aspects of postnatal care (p<0.05). There were not differences in clinical outcomes.
FundingUnknown
ConclusionsMidwifery led care was preferred by women in this study and did not lead to any deficits in clinical outcomes. The authors also note that since burn out and stress have been identified as features of one to one midwifery provision, the team model might have potential for offsetting this problem while still providing care in the spirit of Changing Childbirth.
QualityComparability of groups not reported; randomisation not explained; satisfaction survey validation not ; subjective responses subject to bias
Grading:3Non-analytic studies (for example, case reports, case series)
RID: 659Reference number 819
Twaddle S;Hui LX;Fyvie H;
An Evaluation of postnatal care individualised to the needs of the woman
19939: (3)Midwiferypgs 154 160
Study Type:Cohort
PatientWomen with normal vaginal deliveries who lived in the eastern district of Glasgow were
Characteristics
InterventionStandard pp care and individualised care
ComparisonsClinical outcomes and satisfaction
Study Length6 weeks pp
OutcomesChi square and p values
EffectNS differences in clinical complaints. There was a significant reduction in the mean number of pp visits, p<0.005 and in mean number of different midwives visiting the women in their homes, p<0.005. Women were satisfied with type of care (72%)
FundingChief Scientist’s Office, Scottish Home and Health Department
ConclusionsThis study indicates that women may be satisfied with fewer individualised pp visits.
Quality+Satisfaction survey subject to bias. This is a before and after design which was not randomised and is a convenience sample.

From: Appendix C, Clinical Evidence Extractions

Cover of Postnatal Care
Postnatal Care: Routine Postnatal Care of Women and Their Babies [Internet].
NICE Clinical Guidelines, No. 37.
National Collaborating Centre for Primary Care (UK).
Copyright © 2006, National Collaborating Centre for Primary Care.

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