In total eight focus groups and four individual interviews were held between August and October 2006, with a total of 52 participants. Interviews took place on a few occasions where only one participant attended for a focus group or a participant was unable to attend their nominated session but requested inclusion in the study; in these cases the focus group guide was followed for the interview.
The groups included eight pregnant women, of whom seven were pregnant with their first baby. This was less than the number of pregnant women we aimed to include, but despite a number of different strategies they were a difficult group to recruit. Similarly, only two partners were included in our study, despite strategies such as fliers, letters of invitation, and offering groups at different times and locations. The remaining women who participated were in the postpartum period, and for some this was up to 12 months after the birth of their baby. In one mothers' group the women had been meeting since the birth of their first baby, and most had subsequently had another baby. There were 17 participants who had received public pregnancy care, 11 who had private care and for 24 participants we were unable to determine this from either transcripts or field notes.
We found that a range of issues influenced women's views of postnatal care and the type of care that they wanted or expected. Two global themes emerged and are discussed more fully below, but related to: anxiety and/or fear around the health and wellbeing of the baby, often couched in terms of safety; and the transition to motherhood and parenting, with embedded cultural concepts around this, and a strong sense that the needs of first time mothers were different to the needs of women who had already experienced motherhood. Some of the important basic themes that emerged related to: acquiring skills to care for a new baby; consistent advice from health professionals; continuity of care; lack of staff time; and partner involvement during the postnatal hospital stay. The basic and organisational themes were generally inter-woven, relating back and forward to each other. Systemic factors interacted with the global, basic and organisational themes, with a major one being length of hospital postnatal stay; many issues raised by women were talked about in terms of length of stay and how that did or did not help them achieve some of their expectations. The later discussions around specific alternative postnatal care packages raised no new themes in relation to women's expectations and experiences of postnatal care .
Anxiety and/or fear around caring for a new baby
The first global theme was anxiety and/or fear, and comments related to this theme were often couched in terms of safety. It was clear from the focus groups that participants were very concerned about the safety of their new babies, and were very aware that they had responsibility for another life. This contributed to a perceived need for constant professional support.
...I'd care about the fact that there is someone two minutes away if I need them... if my baby stops breathing... that there is someone on hand and the machinery on hand and... I like that assurance that if anything went wrong... someone was there (primiparous, metropolitan, postnatal).
This theme of anxiety and/or fear contributed to women's thinking and responses on a range of issues, particularly length of postnatal stay. That is, a longer length of stay in hospital gave more opportunity to receive 24 hour medical/professional support. Participants viewed domiciliary visits as important, but it was generally agreed that they did not replace the care available in hospital.
I like that assurance that if anything went wrong... someone was there (primiparous, non-metropolitan, private, postnatal).
Having a midwife physically available was also seen as desirable in order to obtain appropriate care and support – and this 24 hour physical access to midwives was preferable compared to domiciliary midwifery care.
The fact that 24 hours a day there was someone if I needed them I mean even if I had to wait for half an hour just knowing that you know had to wait till three o'clock or whatever their [the domiciliary midwife] appointment was that would just [be] horrific (primiparous, metropolitan, private, postnatal).
This physical presence appeared to be reassuring, as way of allaying some anxiety.
I like that assurance that if anything went wrong... someone was there (primiparous, non-metropolitan, private, postnatal).
Another factor related to anxiety and/or fear was a perception for some women that it was not safe to leave hospital too early as they would not know how to care for a new baby, or might not recognise what was normal in terms of their baby's health and behaviour compared to what was not. The days spent in hospital following birth were therefore seen as very important as a means to learning how to care for a new baby, with access to professional support. This was a recurring theme in the focus group discussions.
I wouldn't get to learn everything I needed to know [in one day] (primiparous, metropolitan, public, antenatal).
The thought of leaving hospital earlier than they had experienced or expected contributed to some women feeling quite anxious, even fearful.
I am six months pregnant and have heard a rumour that hospital stays will be two nights only [soon]. Being a first time mother I find this a little overwhelming. I feel anxious and slightly nervous that I won't feel confident with what I have to do. I believe all the books in the world can't compare to the help, advice and support from midwives and staff in the hospital. Please keep it three nights for first time mums!!! Please! (primiparous, metropolitan, public, antenatal).
Participants also expressed concern about being 'forced' out of hospital before they felt confident looking after their baby; for them it seemed like there was no choice but to be in hospital; they felt they needed to be there.
If I'm in hospital I'm there because medically I need to be there or you know there are issues that are gonna [sic] come up (primiparous, non-metropolitan, postnatal).
Despite participants viewing domiciliary visits as important, it was generally agreed that they would not/did not replace the care given in hospital – having a midwife physically available was seen as desirable to provide safety as well as 'care'.
[Midwife] visits are good, but not really that important. You can always call the hospital or see the GP, [but this] doesn't replace having a midwife on call (primiparous, metropolitan, public, postnatal).
Even if a known midwife was to provide the domiciliary care the thought of home care compared to in hospital care appeared anxiety-producing.
[Having a known midwife at home]...is better than [option of an unknown midwife]... [but] one night in hospital is still a bit scary (primiparous, metropolitan, public, antenatal).
Transition to motherhood and parenting
The concept of transition to motherhood and parenting was the other global theme, and one that emerged in each area of discussion. Within this theme there were the cultural concepts about motherhood and parenting, as well as a strong sense that the needs of first time mothers were different to the needs of women who had already experienced motherhood. There were many aspects of the transition to motherhood that emerged, and the concept was particularly evident in discussion of women's expectations of postnatal care and what they perceived they needed in relation to this, i.e. breastfeeding support and education; professional support while acquiring new skills; and the opportunity to rest and be 'cared for' during this transitional time.
Women felt that breastfeeding was something that they struggled with at home and was a skill that ideally needed to be learnt before hospital discharge. Women saw the acquisition of this skill as a factor in their conception of optimal length of postnatal hospital stay.
I think probably the number one thing for me is that I can breastfeed, that the baby's latching on, I know what to listen for, like I read the books and gotta [sic] have the suck, swallow,...and I'd like to be confident that I knew that definitely (primiparous, metropolitan, public, antenatal).
They often used ability to breastfeed, or their milk coming in, as a metaphor for when they would be happy and confident to go home.
One night is just, just doesn't seem like a long enough time, your milk hasn't come in, you know (primiparous, metropolitan, public, antenatal).
As part of gaining confidence in caring for their babies, and learning how to be mothers, women expressed views that it was better for them to do this in a context of constant professional support, or, at a minimum, the constant availability of support. Most felt this was better achieved in the hospital environment, particularly for first time mothers. The option of staying in hospital for a few days after the birth was seen as very important, as it gave women a chance to learn what to do with their new baby while having physical access to professional support.
One of the reasons we went private was because it was a longer stay and we didn't feel like two nights was adequate preparation to learn to take care of a child ... but I could imagine that with your second child you might want to stay shorter in total...(primiparous, metropolitan, private, postnatal).
Women also placed a great importance on being 'cared for' in hospital.
...it was just really really secure I was a little bit nervous about going home but I could have stayed and lived there forever (primiparous, non-metropolitan, public, postnatal).
However despite the general view that constant professional support ensured the safety of their new baby and provided 'care', postnatal participants reported both positive and negative experiences of their hospital postnatal stay. Women's negative views were driven by a gap between expectation and experience of availability of staff time, continuity of care, consistency of care, and communication from hospital staff. In spite of this though, women were positive overall about their own experience, especially relating to partner involvement, visitors, confidence and feeling 'cared for'. Women commented about how good the midwives had been and used words such as "fabulous", "supportive", "fantastic", and "brilliant".
Hospital was paradoxically experienced as noisy and chaotic by some women, e.g. when in a shared room:
I was uncomfortable, I didn't sleep, the girl next me had a baby that was crying all night (multiparous, non-metropolitan, antenatal).
...yet as isolating and lonely by some that stayed in a private room:
...people have their private rooms and you don't really get to meet other people (primiparous, metropolitan, private, postnatal).
Women felt there was a lack of professional support at times while they were in hospital, commenting that staff were too busy or unavailable to provide the care that they expected:
I got up there and they left me ... to myself. I had no idea about breastfeeding which was hurting... it took them two hours to get to me (primiparous, non-metropolitan, postnatal).
Participants described the frustration they felt at having to explain themselves repeatedly to new staff members and/or receiving contradictory advice from different staff members, and how this impacted negatively on their experience of care.
...the bad thing was probably every shift of midwives you'd get a different midwife... every time so you had to explain yourself again (primiparous, metropolitan, private, postnatal).
Women wanted to have their partners involved in the postnatal experience and expressed pleasure and disappointment according to the level of acceptance of their partner's involvement actually experienced in hospital.
...it was great having the husbands involved (primiparous, metropolitan, private, postnatal).
Not all partners felt well received.
I guess it sort of felt like ... 'go home', they sort of allow for you to stay there but they assumed that you weren't going to be there so always felt like you were always in the way to me. (primiparous partner, metropolitan, private, postnatal).
First time mothers compared with those who had experience
A recurrent theme related to transition to motherhood and parenting as well as to anxiety and/or fear around caring for a new baby was that parents having their first baby needed different care options, compared to parents having subsequent babies. Participants thought that they would be more confident to leave hospital earlier with subsequent babies, but with the first baby needed the professional care and security of being in hospital. For women who had recently had their first baby, the emerging themes related specifically to their expectations and experiences of being at home in the early postnatal period. These included feeling prepared, having family support, their physical health, anxiety and adjustment to parenting, and the hard work associated with a new baby. For those participants who were currently pregnant and expecting their first baby, themes related to concerns about the availability of support, anxiety, a fear of the unknown and not knowing what to expect.
I think [for a] second child it would be... not easier [to stay a shorter time] but different because you know what to expect whereas the first one... she's crying and you have no idea what's going on... and stuff like that... (primiparous, metropolitan, postnatal).
The reality of being at home and caring for their new baby
The preparation for, or expectations of, actually being at home with a new baby were a concern for women. A number of first time mothers talked about anxiety about going home after the birth. One woman, pregnant with her first child commented:
Scary as hell, yeah... so it daunts me ... it's a bit scary, it's not something I'm actually looking forward to, I wouldn't say I'm excited about it you know ...just getting home straight away and the thought of what to pack to go out and how to go out and stuff like that so yeah, a bit scared (primiparous, metropolitan, public, antenatal).
These fears were born out by the experience of other postnatal women:
We couldn't leave the house for eight days we were just completely and utterly shockingly overwhelmed for whatever reason I think back now just the thought of taking him out and driving him somewhere we were just... I don't know overwhelmed is the only word I can think of... everything was just anxious (primiparous, metropolitan, private, postnatal).
For some women who had already had a previous baby there was also anxiety based on their previous experiences at home after the birth:
...last time I had a lot of anxiety... ...lot of panic attacks (multiparous, non-metropolitan, antenatal).
Being prepared for the reality of parenting was talked about in terms of expectations as well as experiences:
Yes pretty hard work a lot more than I thought it would be I expected it to be a lot easier especially the feeding (primiparous partner, metropolitan, private, postnatal).
.....how do you prepare for something that you've got no idea what it's gonna (sic) be like (primiparous, non-metropolitan, antenatal).
Physical pain, and the problems of managing pain, was also raised as an issue related to being at home versus in hospital, although women differed in their preferred location of care for managing pain:
I was a little bit apprehensive about going home just because I was still in a bit of pain and couldn't walk around a lot (primiparous, non-metropolitan, postnatal).
I [didn't] want to be in the hospital...by the next morning I'd just had enough and I wanted out... I couldn't get Panadol [paracetamol] when I wanted it, I ... had a lot of pain ..... and I couldn't get my wheat bags heated up because I wasn't allowed to use the microwave, the nurses were too busy, had to wait like half an hour, I had my mother and my partner at home.... So it was just ridiculous, I don't need to be in hospital, I want to go home and I discharged myself at eight o'clock at night and said 'I'm going home' ... I'd rather be in my bed with my pillows and my blankets and my shower, I'm having Panadol when I want it, not having to record how much (primiparous, non-metropolitan, public, postnatal).
Participants were concerned about the lack of professional support that they would receive at home, despite many also experiencing a lack of professional support available in hospital. Women saw continued access to midwives, through domiciliary midwife visits and/or other means, as an important aspect of professional support following discharge. However many of the women in the groups who had given birth in the private sector had not experienced domiciliary visits.
... [I did not experience domiciliary midwife care]... but if that was available, that would be great, you know, just the questions I have that obviously are not going to come up until they get home, I would ...they would be able to answer them for me, even a help line you know, I could phone them up and go 'what do I do?' you know, or something like that, just like a connection or some sort so I don't feel like I've suddenly left hospital and now you're on your own and that's it (primiparous, metropolitan, public, antenatal).
Women also raised the importance of adequate levels of social (mainly family) support when they first arrived home from hospital, so that they could concentrate on caring for their baby.
I think virtually for the first eight weeks I didn't do much else but feed... mum did the grocery shopping or [partner] did the grocery shopping, mum did the washing... so I was fortunate, my parents live up the road... (primiparous, metropolitan, private, postnatal).
Other women did not have access to this type of support.
"No [I won't have support when I go home]... I don't know anyone in Victoria I [only moved here] about five months ago..." (multiparous, metropolitan, public, antenatal).
Not all comments about being at home were negative, and for some women it was better to be at home rather than hospital:
I [didn't] want to be in the hospital... [I] delivered at night so I had that night and I had a day and a night and by the next morning I'd just had enough and I wanted out... (primiparous, non-metropolitan, public, postnatal).