This study presents the first in-depth views of women in one UK maternity unit obtained at the time they were receiving in-patient postnatal care. Interviews with women were one of several approaches used by the study team to inform how the content, systems and processes of in-patient postnatal care could be revised to better reflect women's needs. Although the focus of the quality improvement initiative was the postnatal ward, it soon became clear that consideration would also have to be given to care processes during the antenatal and intra-partum periods, if transfer from the delivery suite to the postnatal ward and home were to be 'seamless'. The findings have reiterated that although many women were happy with the care they received in hospital, some were disappointed with aspects of their care and others went into hospital with low expectations of their admission to a postnatal ward. Most women were able to identify areas where they felt improvements could be made. Analyses revealed issues about the physical environment of the ward, the approaches and attitude of staff, breastfeeding support, level of practical support and guidance on infant care and how to take care of their health. It is hoped that this work will influence others to consider how to ensure women's views of in-patient postnatal care are captured, given the recognition that user engagement and feedback is essential if high quality patient care is to be achieved .
There is a dearth of in-depth information on UK women's views of their in-patient postnatal care. This is despite the provision of statutory care since the early 20th century, the move of place of birth from home to hospital from the 1970's onwards and findings from large national surveys that this is the area of maternity care that women find the least satisfactory [2, 5, 15]. A survey of women's experiences of postnatal care published in 2000  was the first in the UK to specifically focus on this aspect of maternity care from the women's perspective, and considered community as well as hospital-based care. Women who had given birth within the previous year were accessed through the member's journal of the National Childbirth Trust (NCT) and an on-line internet site for parents, with 960 completed surveys received. During the first three days following the birth, when women were most likely to be on the postnatal ward, around half of this self-selected group of women reported that they received the information, advice, care and emotional support that they needed. One in ten reported they received very little or no information and a quarter suggested they received no emotional support. The NCT recently published the results of a postnatal care survey undertaken during 2009/2010 involving 1260 first time mothers, most of whom were NCT members (95%) . The authors concluded that there had been limited improvement in postnatal care over the last decade, with some evidence of a decline in meeting woman centred quality-standards, despite greater investment in the NHS and publication of NICE postnatal care guidance.
The experiences of women in the current study are reflected in studies from other countries, where a similar system of hospital-based birth care is the prevalent model, most notably Sweden and Australia [6, 8, 9, 33]. Of note is that several of these studies were also surveys which questioned women several weeks or months following the birth. Nevertheless, the consistency of findings in our study and the earlier studies highlights the continuing low priority accorded to the crucial hours and days following birth. This could potentially negate a good birth experience and a positive start to parenting for the mother, her partner and the infant. The themes we derived from the interview data confirm findings of other researchers [8, 33], suggesting that despite differences in context, culture, service organisation and delivery across different Western countries, women's views of their needs and expectations following birth are remarkably similar.
With respect to the physical environment of the ward, a number of the ward routines were viewed by the women in the current study as not conducive to them sleeping or resting following birth. Routines reflected those of a 'traditional' acute medical or surgical ward rather than organised to optimise recovery from birth. The early morning waking was problematic for some women as many would have been awake during the night to feed their babies. Similarly the need to conduct non-urgent medical procedures such as removing a urinary catheter at 6 am in the morning was viewed negatively. It would be useful to consider if in-patient postnatal wards need to have such inflexible routines. Rather than placing women at the centre of care, ward routines likely to have been established as part of an acute medical organisation may be more appropriate for the staff than for women. The lack of flexibility in the in-patient environment has been reported elsewhere. Rudman and Waldenstrom  reported on women's negative experiences of hospital postnatal care in a prospective longitudinal study of 2783 Swedish-speaking women surveyed in early pregnancy and at two months and one year postpartum. Negative statements about postnatal hospital care included dissatisfaction with the physical environment of the ward, the room temperature being too high, shabby rooms and bad mattresses. Singh and Newburn  in their UK survey also reported that women found postnatal wards too hot, too noisy, and rules about visiting on the wards 'problematic'.
The importance of a two hour 'quiet time' each day, when visitors were not allowed onto the wards, was reported as a positive routine by several women in our study. A busy postnatal ward environment, where staff and visitors are coming and going could problematic for some women in terms of rest and recuperation - it also contrasts with the emphasis on the importance of a peaceful birth environment, where great care is taken to protect a woman's privacy and limit those who enter the birth room. Many women are on 'view' for the duration of their in-patient postnatal stay with all inter-actions and conversations with staff and relatives conducted in full sight and sound of the other women and their visitors. Interestingly, in our interviews lack of privacy did not appear to be problematic, indeed some women reported that they preferred to be in a room with others and they did not want to be alone; the issue is protecting time to enable women to rest. Access to the postnatal wards by visitors is an on-going area of contention given the need to promote maternal well-being but also acknowledge birth as a celebratory social event and important transition for the woman and her partner. Restricted visiting has been viewed as detrimental for the partner as it could interrupt their interactions with their infant, and influence their experience and satisfaction with postnatal care [34, 35]. Conversely 'open' visiting may limit a woman's opportunity for rest and opportunities to speak to a midwife if she has any particular concerns. Staff may not wish to interrupt a woman if she is perceived as 'busy' with her visitors.
Previous studies have highlighted the negative impact that staff attitudes and poor communication have on women [6, 8, 32]. Women in our study for the most part, described staff very positively, although a small minority reported that a member of staff had spoken to them in a manner which they thought was inappropriate. Brown et al  found that the greatest effects on women's overall rating of their in-patient care were based on women's inter-action with their caregivers, including how sensitive and understanding caregivers were, how rushed they seemed and if advice and support were offered. There is also evidence that the attitude of postnatal ward staff towards fathers is problematic, with positive encouragement around the transition to parenthood lacking , although this was not a finding of our study. The women in our study valued staff being friendly and helpful which concurs with the recommendations of previous studies that there should be a greater focus on the communication and listening skills of postnatal staff [6, 35]. Concerns about midwifery staffing levels in the NHS is adding to pressures on the postnatal wards [32, 36], resulting in women feeling guilty about calling staff as illustrated in our study. This also emphasises the perception commonly reported  that women view staff on the wards as too busy and further calls into question for whose benefit the current organisation and delivery of in-patient postnatal care is intended.
Women's views of support for breastfeeding also highlighted the importance of staff attitudes. The level of support women received on the postnatal ward for breastfeeding prompted mixed responses. It was disappointing that some women found staff unhelpful which left them with the impression that they did not want to support breastfeeding, but also encouraging that others had a very positive experience of staff support. There was particular praise for the nursery nurses, which suggests that there is an important role for all members of postnatal ward teams to play in support for breastfeeding. The crux, as evidenced in the responses reported here, was how individual members of the postnatal team interacted with women, which is likely to be influenced as much by workload pressures, as their knowledge and awareness of how to inter-act with women who wish to breastfeed. Dykes  in an ethnographic study of encounters between midwives and breastfeeding women in postnatal wards in England reported that the needs of breastfeeding women for informational and practical support, as well as for emotional, and esteem needs were largely unmet as a result of lack of midwifery time, no established relationship with the women, and the structural constraints of a medicalised organisation. Dykes  also identified that it was not just organisational culture which determined the nature of interactions between midwives and women. It was also the encounter with individual midwives who had a range of approaches to supporting breastfeeding women, some facilitative and some didactic, a finding which our data supports. Strategies to increase breastfeeding, such as the WHO Baby Friendly Hospital Initiative  include the need to train all health staff in skills to implement the breast-feeding policy. Consideration should also be given to ensuring staff are aware that the way they speak to women about breastfeeding and other aspects of postnatal care could have a considerable and lasting impact on women's experiences.
With respect to unmet information needs, NICE  recommends women and their partners receive relevant and timely advice tailored to their individual needs commencing with transfer to the postnatal ward. Women in this study valued information to support their transfer home but also wanted information on their admission to the ward about ward routines and the ward layout. Frequent reference was made to the requirement for advice on practical care of their baby such as bathing and nappy changing. During the last decade the duration of in-patient stay has declined considerably in the NHS . Early discharge home does not appear to have an effect on maternal health or breastfeeding outcomes , but has resulted in a system of care where staff have to complete all admission and discharge processes within severe time constraints, leaving little time to implement the care women perceive they need and expect they will receive from their in-patient stay such as advice on how to care for their babies.