Having a Baby in Scotland 2015: Maternity Care Survey

Chapter 4: Care After Birth in Hospital and at Home: Postnatal Care

Summary of key results

Care in hospital

• 54% of women rated their postnatal stay in hospital as excellent.
• 40% of women only sometimes or did not receive the information or explanations that they needed.
• 31% said they were not always treated with kindness and understanding.
• 58% of women said their partner or other person close to them could stay as much as they wanted.
• 65% received relevant information and 62% active help and encouragement about infant feeding.
• 55% said that they always received consistent advice about feeding their baby.
• Women's comments on care in hospital highlighted the central importance of supportive compassionate care from midwives as well as practical help and assistance with self-care and infant feeding. Where this was present women's experience was enhanced, in its absence mothers felt vulnerable and anxious.

Care provided in the community after the birth

• 58% rated the care they received in the community after the birth as excellent.
• 99% of women received a visit from a midwife at home, 50% saw a midwife three or four times.
• 51% of women saw the same midwife all or most of the time.
• 98% of women had a telephone number to contact a midwife or midwifery team, 85% who did so said that they always got the help that they needed.
• 81% said midwives always took their personal circumstances into account when giving advice.
• 74% received help and advice about their baby's progress.
• 56% were given enough information about their own physical recovery and 57% were given enough information about emotional changes that they might experience.
• As with antenatal care, comments highlighted the importance of continuity of care and the opportunity to develop relationships; this was associated with consistent advice and support. Seeing different midwives was frustrating and stressful for women. Women valued consistent feeding advice and support. Many women felt uninformed about their own health and recovery from birth.

Postnatal care in hospital - Length of stay in hospital after the birth

4.1 The length of hospital stay following the birth has gradually declined across Scotland (and many other countries) in recent years. However, the survey found no change from 2013, in the length of time women reported spending in hospital after giving birth. Around one quarter of women said that they stayed in hospital for less than 24 hours, with the majority of women saying that they remained in hospital for between one and four days (Table 24). Most women (78%) felt that on reflection, the length of time they remained in hospital was about right with similar proportions saying either their stay was too long or too short.

Table 24. Length of postnatal hospital stay

How long did you stay in hospital after your baby was born?
	2013		2015
	% (n=2,311)	Confidence Interval	% (n=1,985)	Confidence Interval
Up to 12 hours	11	(9.6 , 11.7)	11	(9.8 , 12.2)
More than 12 hours but less than 24 hours	16	(15.1 , 17.7)	15	(14.1 , 16.9)
1 to 2 days	36	(34.7 , 38.2)	40	(38.0 , 41.9)
3 to 4 days	25	(23.4 , 26.5)	22	(20.5 , 23.9)
5 or more days	12	(10.4 , 12.7)	11	(10.1 , 12.7)
Looking back, do you feel that the length of your stay in hospital after the birth was...
	2013		2015
	% (n=2,261)	Confidence Interval	% (n=1,940)	Confidence Interval
About right	77	(75.2 , 78.3)	78	(76.0 , 79.4)
Too long	14	(12.4 , 15.0)	11	(10.0 , 12.7)
Too short	10	(8.5 , 10.6)	11	(9.7 , 12.2)

Care, information and advice

4.2 The 2013 report highlighted that many women did not feel that they always received the information that they required while they were in hospital following the birth of their baby. This situation appears largely unchanged with 40% of women saying that they only sometimes or did not receive the information or explanations that they needed (Table 25). This varied by Health Board, with more women in NHS Borders saying that they received this information than those in NHS Grampian (79% compared to 52%) Similarly almost one third of women felt that they were not always treated with kindness and understanding during their postnatal hospital stay. Again, women who received care in NHS Borders reported more positive experiences in this area.

Table 25. Care, information and advice

Thinking about the care you received in hospital after the birth of your baby, were you given the information or explanations you needed?
	2013		2015
	% (n=2,311)	Confidence Interval	% (n=1,983)	Confidence Interval
Yes, always	61	(59.4 , 62.9)	60	(58.0 , 62.0)
Yes, sometimes	30	(28.6 , 31.9)	32	(29.7 , 33.5)
No	9	(7.5 , 9.6)	8	(7.2 , 9.5)
Thinking about the care you received in hospital after the birth of your baby, were you treated with kindness and understanding?
	2013		2015
	% (n=2,316)	Confidence Interval	% (n=1,982)	Confidence Interval
Yes, always	67	(65.4 , 68.8)	70	(67.6 , 71.4)
Yes, sometimes	28	(26.4 , 29.7)	27	(25.1 , 28.8)
No	5	(4.0 , 5.6)	4	(2.8 , 4.3)

4.3 A new question in the 2015 survey asked women whether their partner, or other person close to them was able to stay with them as much as they wanted during their postnatal stay in hospital. Only 58% of women said that they were (Table 26).

Table 26. Partners accommodated in the postnatal ward

Thinking about your stay in hospital, if your partner or someone else close to you was involved in your care, were they able to stay with you as much as you wanted?
	2015
	% (n=2,036)	Confidence Interval
Yes	58	(55.8 , 59.7)
No, as they were restricted to visiting hours	32	(30.5 , 34.2)
No, as there was no accommodation for them in hospital	12	(10.5 , 13.1)
No, they were not able to stay for another reason	2	(1.8 , 3.0)
I did not have a partner or companion with me	1	(0.4 , 1.1)

Hospital Environment

4.4 There appeared to be some improvement from the 2013 survey, in women's perception of the cleanliness of their hospital environment with 64% of women reporting that the toilets were very clean, up from 60% in 2013 (Table 27).

Table 27. Hospital environment

Thinking about your stay in hospital, how clean was the hospital room or ward you were in?
	2013		2015
	% (n=2,307)	Confidence Interval	% (n=1,982)	Confidence Interval
Very clean	69	(67.6 , 70.9)	72	(70.1 , 73.7)
Fairly clean	28	(26.7 , 29.9)	26	(24.0 , 27.6)
Not very clean	2	(1.5 , 2.5)	2	(1.3 , 2.5)
Not at all clean	1	(0.2 , 0.8)	0	(0.1 , 0.7)
Thinking about your stay in hospital, how clean were the toilets and bathrooms you used?
	2013		2015
	% (n=2,301)	Confidence Interval	% (n=1,986)	Confidence Interval
Very clean	60	(58.4 , 61.8)	64	(61.9 , 65.8)
Fairly clean	34	(32.1 , 35.5)	31	(29.3 , 33.1)
Not very clean	5	(3.8 , 5.4)	4	(2.9 , 4.5)
Not at all clean	2	(1.0 , 2.0)	1	(0.8 , 1.8)

Infant feeding

4.5 Scotland has historically had low rates of breastfeeding in comparison to other similar European countries and increasing the rate of successful breastfeeding is a key target for long term improvements in infant and population health. Despite considerable research and NHS focus on strategies to increase the number of babies breast fed, rates remain low. The survey findings indicate however, that the majority of women breast feed, to some extent, during the first few days following birth (Table 28). Overall 52% of women said that their baby was exclusively breast fed in the first few days, with 28% saying that they exclusively formula fed and 19% that they used both breast and formula milk. Almost one quarter of women who said that they exclusively formula fed reported that they did try to breastfeed their baby at least once.

Table 28. Infant feeding

In the first few days after the birth how was your baby fed?
	2013		2015
	% (n=2,340)	Confidence Interval	% (n=2,007)	Confidence Interval
Breast milk (or expressed breast milk) only	49	(46.8 , 50.4)	52	(49.6 , 53.6)
Both breast and formula (bottle) milk	21	(19.4 , 22.3)	19	(17.4 , 20.6)
Formula (bottle) milk only	30	(28.1 , 31.4)	28	(26.4 , 30.0)
Other	1	(0.5 , 1.1)	1	(0.7 , 1.6)
Did you ever try to breastfeed you baby (even if it was only once)?
	2013		2015
	% (n=687)	Confidence Interval	% (n=588)	Confidence Interval
Yes	23	(19.3 , 25.8)	23	(19.3 , 26.6)
No	77	(74.2 , 80.7)	77	(73.4 , 80.7)

Infant feeding - support and advice

4.6 Establishing parenting confidence in infant feeding is a key aspect of maternity care and many women require support and advice about infant feeding whether they choose to breast feed or formula feed their baby. The previous survey indicated that women often reported receiving conflicting advice about aspects of infant feeding and this relates both to formula feeding and breast feeding. Women were asked whether they received relevant advice about feeding their baby from their midwife or midwifery team, while they were pregnant (Table 29). Only 65% said that they definitely did. Most women (84%) said that they felt that their decisions about how they wanted to feed their baby were always respected by staff (Table 30), however, only 62% of women said that midwives and other health professionals gave them active support and encouragement about feeding their baby. This was lowest in NHS Ayrshire & Arran (at 52%) and highest in NHS Tayside (71%). As in the 2013 survey only just over half of women (55%) said that they always received consistent advice from health professionals about feeding their baby and a considerable number of women (17%) said that they did not receive consistent advice.

Table 29. Infant feeding advice during antenatal care

During your pregnancy did midwives or the midwifery team provide relevant information about feeding your baby?
	2013		2015
	% (n=2,212)	Confidence Interval	% (n=1,912)	Confidence Interval
Yes, definitely	68	(66.7 , 70.2)	65	(62.8 , 66.9)
Yes, to some extent	26	(24.6 , 28.0)	28	(26.3 , 30.1)
No	5	(4.4 , 6.1)	7	(5.9 , 8.1)

Table 30. Infant feeding advice and support

Were your decisions about how you wanted to feed your baby respected by staff?
	2013		2015
	% (n=2,314)	Confidence Interval	% (n=2,001)	Confidence Interval
Yes, always	82	(80.5 , 83.3)	84	(82.1 , 85.1)
Yes, sometimes	15	(13.6 , 16.1)	13	(12.1 , 14.9)
No	3	(2.6 , 3.9)	3	(2.2 , 3.6)
Did you feel that midwives and other health professionals gave you consistent advice about feeding your baby?
	2013		2015
	% (n=2,141)	Confidence Interval	% (n=1,875)	Confidence Interval
Yes, always	57	(55.0 , 58.8)	55	(53.2 , 57.4)
Yes, sometimes	27	(25.6 , 29.0)	28	(25.8 , 29.7)
No	16	(14.4 , 17.2)	17	(15.3 , 18.6)
Did you feel that midwives and other health professionals gave you active support and encouragement about feeding your baby?
	2013		2015
	% (n=2,186)	Confidence Interval	% (n=1,906)	Confidence Interval
Yes, always	63	(61.0 , 64.7)	62	(60.3 , 64.4)
Yes, sometimes	26	(24.8 , 28.1)	29	(26.6 , 30.4)
No	11	(9.5 , 11.9)	9	(7.9 , 10.4)

How women rated their postnatal care in hospital

4.7 Overall 54% of women rated the care that they received in hospital after giving birth as excellent with 32% rating their care as good. Experiences were reported as being particular positive in the NHS Borders and NHS Fife, and less so in NHS Grampian (where 17% of women felt that their postnatal care was "Fair").

Chart 3 - Overall rating of postnatal care in hospital

What women said about their postnatal care in hospital

4.8 In total 757 women chose to make comments on their postnatal care in hospital representing 37% of the overall questionnaire sample. The majority of the comments (around 80%) in this section were, in general, negative although a number of women expressed concern regarding some aspects of their experience but were nonetheless very positive about hospital staff and around 20% of comments were entirely positive. Comments made were particularly wide ranging but in general reflected survey findings relating to care and compassion, information and advice, and support for feeding and other aspects of parenting support.

Care and support

4.9 Many women commented about the care and support that they received from staff, and especially midwifery staff, whose attitude, support and clinical expertise made a great difference to the women's experiences of postnatal care. A number of aspects were highlighted positively by women including approachability and helpfulness of staff.

'Very attentive staff who were always on hand to ask questions to and gain help'.

4.10 Women appreciated the reassurance of having supportive staff around in the early days and staff who were able to provide a balance between space for them to get to know their new babies and being available for help and advice when needed.

'All staff were outstanding. Being new parents isn't easy and all staff were supportive both in presence and with helpful hints and tips to care for our baby'.

4.11 Qualities of being caring, sensitive, supportive and helpful with breastfeeding and infant care advice were particularly valued, and staff having time for them was an important theme. A number of women commented that although aspects of their care had been good or excellent, this was despite staff being perceived as very overstretched and overworked.

'The midwives and staff were excellent but stretched. They were as helpful as they could be but were very, very busy'.

4.12 Unfortunately some women did feel that staff were so overstretched and so few in number that it was not possible for them to provide adequate care. This led some women to feel that they were 'in the way' or an inconvenience to the busy staff team.

'The midwives on the ward were too busy and did not have time to help with bottle feeding, changing nappies or bathing. As a first time mum, I felt that I needed more assistance. I actually felt like I was an inconvenience to the midwives at times'.

4.13 In addition to the women who felt they had been too much left to fend for themselves during their postnatal stay, there were a number of women who commented specifically on being left alone or being 'forgotten about' by hospital staff.

'I felt very alone in the ward after having my baby and felt the staff just left me to it and did not check on me. I felt very vulnerable as I had an epidural and could not move'.

Kindness and compassion

4.14 The kindness and supportiveness of staff was also commented upon positively, both when women had felt vulnerable following a difficult birth or where they were well following delivery but nonetheless appreciated care and attention post-natally.

'Was brilliant, totally cared for. Staff helped shower and dress, as struggled due to stitches. Midwife was gentle and kind. Fantastic care'.

4.15 However, a number of women reported negative experiences of hospital staff. Sometimes the difficulties experienced by women were linked to staff being overstretched, but this is not always the case. The issues that women have commented on include staff being rude, condescending, inattentive, or unhelpful.

'Some of the nurses were fantastic but others looked down their nose at me and when I would ask questions, they made me feel as if they had no time or desire to listen to me'.

'Some of the team were excellent. Some were very ignorant, unsupportive, impatient and some even had lack of care'.

4.16 Some women unfortunately felt that an overall positive experience of care had been marred by staff members whose behaviour had upset them.

'Only one member of staff ruined it with her attitude towards me. I feel it was not needed. She was just rude! Otherwise I would have rated my care as excellent'.

Physical care, meeting basic care needs

4.17 There were a number of comments from women who felt that they were not afforded an acceptable level or care and dignity with other physical needs that they had. The comments vary in the degrees of perceived seriousness and impact, from women who were unhappy with the time it took for them to receive clean sheets or bedding post-birth to women who were frightened getting up to care for their babies and themselves following a Caesarean delivery or epidural without support. Nevertheless all the women who commented about this aspect of their care were in some way suggesting that their basic needs for personal cleanliness, dignity, or mobility had been unrecognised or unmet in the care they and their new babies received.

4.18 Following the birth, good nutrition is important for new mothers and their babies, particularly for successful breastfeeding. A small number of women commented positively on the hospital food and the way in which staff met their basic needs well.

'After giving birth I was given plenty of food and drinks. This really boosted my energy back up. I was so pleased'.

4.19 However, there were a larger proportion of women who commented in order to express dissatisfaction with the way their basic needs were met post-natally.

'I have never seen such apathy in the care given to mums and babies postnatal. Myself and other new mums were left without adequate analgesia, water and food. We were treated by some staff, as a nuisance. As an experienced mum, I required very little help, only to address basic issues such as pain relief, hydration, nutrition, privacy and dignity, which staff regularly failed to address'.

4.20 A number of women commented negatively about the food and fluids they were provided with during their post-natal stay in hospital. Some women had difficulty accessing food at all, or in accessing meals that were appropriate to their needs or dietary restrictions.

'Food within hospital was poor with evening snack not provided due to "no food on ward". How do you expect mums to feed baby by breast!'

'One thing I would like to point out that some patients belong to different religions and they have some food restriction like vegetarian or halal food. I stayed there for two days and ask for them to (provide) halal food. They gave me a list to choose the menu for two time lunch and dinner but didn't get anything after that. I said to them and they give me a list again for the next day but they didn't order that again; that is shameful…'

4.21 Sufficient rest was another basic need that some women reported it being difficult to come by on the post-natal ward. The noise of staff, other patients and their babies, and being woken up by staff for monitoring were all mentioned as making it difficult to rest.

'Often there are too many interruptions for silly things, "do you want tea?" etc. when all you really want is a rest'.

'Was on one occasion woken to take blood or some details which is not ideal when you have just given birth. I felt it would have been more appropriate to do checks whilst I was awake, the ward was not busy'.

Recovery from birth

4.22 More women were concerned by a lack of focus on maternal recovery following the birth, and felt that post-natal care was baby focused rather than holistically caring for mother and baby together. Some women who felt they had not received enough information about tears or episiotomies sustained during delivery, and on how they should care for themselves to encourage healing.

'I received no proper aftercare or advice about my condition or how to look after myself. It is also assumed you know how to look after a baby which is very hard for first time mums'.

'I was not told that my episiotomy was left as an open wound. Stitched on the inside and left to heal from the inside out. I was not informed how long it would take to heal or when I would start to feel better. I got this information from my named midwife and GP'.

4.23 A few women commented that they would have simply appreciated having a check from a doctor for themselves as well as their babies before they were discharged.

'I received a spinal after the birth to remove the placenta. I was not checked by or did not see a doctor before I was discharged. I would have liked to'.

Information and advice

4.24 The extent to which women can expect practical help and support from hospital staff in caring for their babies is a question that arises from the comments. Some women did feel that they should have been given more help, guidance and 'hands on' support in caring for their infants, and that they had instead been left alone and expected to 'get on with it' when they had not felt able or confident to do so. There were a small number of women who highlighted a lack of continuity in care and consistency of advice as problematic and a small minority of women who felt that lack of communication or information sharing had caused significant problems for them and their babies, or made them feel they were not receiving person-centred care.

'Send everyone on the same course! Some staff tell us to do things, then others attended and asked why we were doing what we were doing - dummy, feeding, nappies, etc.'

'Midwives did not seem to get a handover - needed to repeat everything including my medical history. Just another mother and baby that needed to be processed'.

4.25 It is a priority for women post-birth to gain confidence in feeding and caring for their babies. Women appreciated staff who had time to help them to establish breastfeeding, who could support their choices in relation to feeding and who could answer the questions they had about looking after their infants.

'I did feel silly asking for help with breastfeeding, but the nurses couldn't have been nicer and more helpful. I was very grateful for this help during the night, when family were gone'.

'The hospital midwives were very good and provided excellent support and advice on breastfeeding'.

4.26 However, some women were disappointed by a lack of breastfeeding support, inconsistent advice, or an approach that was experienced as invasive or judgemental.

'I had difficulties breastfeeding and I felt like I had too many people telling me different ways of trying to breastfeed. Although they were just trying to be helpful, I just needed a bit of consistency'.

4.27 A small number of women reported that their feeding choices had not been respected or supported by staff.

'My baby struggled to feed immediately after birth and I was constantly offered a formula bottle milk rather than a pump to express my milk. I did not like this'.

4.28 Several women indicated that they had been unable to continue with breastfeeding due to lack of support or that they had persevered despite the poor support and advice they had received in hospital.

'If I had received more help and guidance regarding breastfeeding I feel I would have been able to continue. Specifically in hospital, I was shown once how to latch on by a very harassed nurse'.

4.29 As well as support for feeing their babies, there were a small number of women who indicated there could have been more support with other aspects of infant care whilst in hospital.

'I was not shown how to bathe my baby before being discharged'.

4.30 And some women who felt that this aspect of their care had been good.

'The ward nurses and staff were all fantastic! I was looked after with 100%, very caring and helpful through my stay and were always at hand to help me with my child'.

Partner involvement

4.31 Some women also indicated that they found their separation from their partners and family as a result of restricted visiting hours very difficult. There was a view expressed in some of the comments that policies need to change to allow fathers to be more involved in caring for their babies and supporting their partners where a post-natal stay in hospital is necessary for mother and baby.

'I wanted my partner to stay with me but only found out after the birth that he could not - this made me apprehensive. As a first time mum I felt unsupported overnight because of this'.

'Overall, it was excellent. But it would have been good to have accommodation for my husband to stay overnight'.

Length of Stay and Discharge Home

4.32 A number of women commented upon the length of time they had stayed in hospital, and the process of being discharged home. Some women had appreciated spending some time with their babies before going home to older children.

'I was given the opportunity to stay overnight but we decided to go home to our other children. Being able to relax in the ward with our new baby (for 8 hours) was a very important time for us'.

4.33 Comments were positive where staff had been able to gauge parents' confidence and to respect their wishes in terms of length of stay.

'My local hospital did not specify when I went home. I was able to choose for myself as long as everything was fine with the baby. There was never a time limit or them telling me I had to be out within a certain time which I really appreciated. I received excellent support for breastfeeding whilst there and at home'.

4.34 However some women commented that they felt they had been discharged too soon before they had recovered fully from the birth and established feeding, sometimes leading to problems later on.

'The policy for the unit was to send mothers home on the same day. I feel this is too short, especially as I had not managed to establish breastfeeding. I had great follow-up support from staff but do feel more time in hospital would be better for most mothers'.

4.35 There were a number of comments specifically about the process of being discharged. Mainly these concerned a lengthy wait for discharge due to staff being too busy to complete the necessary checks or paperwork.

'The staff were always kind and helpful but they were clearly too busy. They proposed a 6 hour discharge but in fact didn't really get round to checking on us until about 6 hours, they were really too busy and it was not fair on them, they were trying their hardest but in a compromised position'.

Care at home after the birth

4.36 All women currently receive midwifery care following discharge from hospital for a period of at least 10 days after they give birth. Current guidance advises that postnatal care should be planned to ensure continuity of care and care that is individualised to the needs of mothers and babies. With a focus on practical advice and information on recovery following birth, including signs and symptoms mothers should be aware of as well as practical advice and information on infant feeding and coping strategies.

4.37 Overall, women appear to be seeing a midwife slightly less often than in 2013 with 11% compared to 9% saying that they saw a midwife only once or twice after they went home from hospital. The majority of women (82%) said that they felt that they saw a midwife around the right number of times (Table 31). Almost all women (99%) reported that they had been visited in their home by a midwife with 29% of women saying that they had also seen a midwife in a clinic following the birth of their baby (Table 31a).

Table 31. Midwife care following hospital discharge

How many times in total did you see a midwife after you went home?
	2013		2015
	% (n=2,268)	Confidence Interval	% (n=1,944)	Confidence Interval
1 to 2	9	(8.2 , 10.4)	11	(9.8 , 12.4)
3 to 4	50	(48.1 , 51.8)	50	(48.1 , 52.3)
5 to 6	26	(24.8 , 28?)	25	(23.5 , 27.1)
>= 7	14	(13.1 , 15.6)	13	(12.0 , 14.8)
Would you have liked to have seen a midwife...
	2013		2015
	% (n=2,331)	Confidence Interval	% (n=2,003)	Confidence Interval
More often?	16	(14.3 , 16.9)	13	(11.2 , 13.9)
Less often?	3	(2.8 , 4.1)	6	(4.6 , 6.5)
I saw a midwife as much as I wanted	81	(79.5 , 82.4)	82	(80.3 , 83.5)

4.38 The majority of women said that they were not offered the option of a clinic visit. For those who had seen a midwife in a clinic around three quarters said that this was completely convenient for them however, for 26% of women the clinic was only convenient to some extent or not at all. Most women (80%) said that they were not offered a choice of where they could see the midwife after they went home from hospital (Table 32).

Table 31a. Location for postnatal care

Since your baby's birth have you been visited at home by a midwife?
	2015
	% (n=1,971)	Confidence Interval
Yes	99	(98.1 , 99.1)
Yes, but I had to contact them to arrange this	1	(0.8 , 1.8)
No, this was not offered	0	(0.0 , 0.3)
Since your baby's birth have you seen a midwife at a clinic?
	2015
	% (n=2,006)	Confidence Interval
Yes	28	(26.2 , 29.8)
Yes, but I had to contact them to arrange this	1	(0.7 , 1.6)
No, this was not offered	58	(55.8 , 59.8)
No, I was visiting or staying near my baby in a neonatal unit (NNU, NICU, SCBU)	3	(2.0 , 3.3)
No, for another reason	10	(9.2 , 11.7)

Table 32. Choice of location for postnatal care

Was it convenient for you to see a midwife at a clinic?
	2015
	% (n=561)	Confidence Interval
Yes, completely	74	(70.0 , 77.6)
Yes, to some extent	23	(18.9 , 26.2)
Not at all	4	(2.0 , 5.2)
Were you given a choice about where you saw a midwife?
	2015
	% (n=1,808)	Confidence Interval
Yes	20	(18.7 , 22.1)
No	80	(77.9 , 81.3)

Continuity of care

4.39 Just over half of women (51%) reported seeing the same midwife either all or most of the time, an increase from 2013, in the number of women reporting that they always saw the same midwife for both antenatal and postnatal care. Overall 71% of women said that they saw their named midwife at least some of the time during their postnatal care after leaving hospital (either at home or in a clinic) (Table 33).

Table 33. Continuity of postnatal care at home

If you saw a midwife for your care at home after birth, did you see the same one every time?
	2013		2015
	% (n=2,254)	Confidence Interval	% (n=1,953)	Confidence Interval
Yes, every time	17	(15.8 , 18.6)	17	(15.7 , 18.9)
Yes, most of the time	34	(32.3 , 35.8)	34	(31.9 , 35.8)
No	49	(46.9 , 50.6)	49	(46.8 , 50.9)
Did you see your named midwife at home or in a clinic after birth?
			2015
			% (n=1,679)	Confidence Interval
Yes, I saw them all / most of the time			40	(37.8 , 42.3)
Yes, I saw them some of the time			31	(28.6 , 32.7)
No			29	(27.2 , 31.4)
Did you see the same midwife for both your antenatal and postnatal care?
	2013		2015
	% (n=2,308)	Confidence Interval	% (n=1,991)	Confidence Interval
Yes, always	10	(8.6 , 10.8)	14	(12.2 , 15.0)
Yes, most of the time	34	(32.6 , 36.1)	37	(34.8 , 38.6)
No, but I would have liked to	28	(26.4 , 29.7)	25	(23.2 , 26.7)
No, but I did not mind	28	(26.3 , 29.6)	25	(23.0 , 26.5)

Accessibility of services

4.40 Almost all women said that they had a telephone number for contact with a midwife or midwifery team and a large majority of women who did so (85%) reported always getting the help that they needed (Table 34).

Table 34. Access to midwifery care during postnatal care at home

When you were at home after the birth of your baby, did you have a telephone number for a midwife or midwifery team that you could contact?
	2013		2015
	% (n=2,318)	Confidence Interval	% (n=1,997)	Confidence Interval
Yes	98	(97.6 , 98.6)	98	(97.6 , 98.7)
No	2	(1.4 , 2.4)	2	(1.3 , 2.4)
If you contacted a midwife or midwifery team were you given the help you needed?
	2013		2015
	% (n=1,418)	Confidence Interval	% (n=1,249)	Confidence Interval
Yes, always	86	(84.5 , 87.9)	85	(83.2 , 87.2)
Yes, sometimes	10	(8.4 , 11.4)	12	(10.0 , 13.7)
No	2	(1.5 , 2.9)	1	(0.8 , 2.2)
No as I was not able to contact a midwife	2	(1.0 , 2.3)	2	(0.8 , 2.2)

Woman centred care

4.41 Most women felt that the midwives they saw during their postnatal care at home always listened to them although 21% felt that this was not always the case. There was an increase from 2013 in the number of women who felt that their midwife or midwives always took their personal circumstances into account when giving advice, however 19% said that they only sometimes or did not do so. In relation to the trust and confidence women had in their midwives there was no change to the findings of the 2013 survey, 78% of women said that they always had trust and confidence in their midwives while just over one in five women said that this was not always the case (Table 35).

Table 35. Woman centred postnatal care

Did you feel that the midwife or midwives that you saw always listened to you?
	2013		2015
	% (n=2,323)	Confidence Interval	% (n=2,008)	Confidence Interval
Yes, always	78	(76.5 , 79.5)	79	(77.3 , 80.7)
Yes, sometimes	19	(17.6 , 20.4)	18	(16.7 , 19.9)
No	3	(2.4 , 3.7)	3	(2.0 , 3.3)
Did the midwife or midwives that you saw take your personal circumstances into account when giving you advice?
	2013		2015
	% (n=2,052)	Confidence Interval	% (n=1,864)	Confidence Interval
Yes, always	78	(76.6 , 79.9)	81	(79.6 , 83.0)
Yes, sometimes	19	(17.1 , 20.2)	17	(14.9 , 18.1)
No	3	(2.4 , 3.8)	2	(1.5 , 2.8)
Did you have confidence and trust in the midwives and midwifery team you saw after going home?
	2013		2015
	% (n=2,315)	Confidence Interval	% (n=2,011)	Confidence Interval
Yes, always	78	(76.3 , 79.3)	78	(76.1 , 79.5)
Yes, sometimes	19	(17.5 , 20.4)	19	(17.8 , 21.1)
No	3	(2.6 , 3.9)	3	(2.1 , 3.5)

In the six weeks after birth…

4.42 Women were asked about the care that they received in the six weeks following birth. For most mothers and babies care will be transferred from the midwifery team to the health visitor at about 10 days after the birth. This means that the following questions ask women about care they may have received from midwives and health visitors and possibly other members of the multi professional care team such as the GP.

4.43 It appears that the large majority of women did receive some practical aspects of care and advice. Almost all said that they were told that they would need to arrange a postnatal check-up at between four and six weeks after the birth. Similarly almost all were given advice about contraception. Overall 95% of women said that they were offered contraceptive information or advice, up from 92% in 2013 (Table 36).

Table 36. Advice on the postnatal check-up and contraception

Did a midwife tell you that you would need to arrange a postnatal check-up of your own health? (Around 4-8 weeks after the birth)
	2013		2015
	% (n=2,260)	Confidence Interval	% (n=1,966)	Confidence Interval
Yes	93	(91.7 , 93.7)	92	(91.1 , 93.3)
No	7	(6.3 , 8.3)	8	(6.7 , 8.9)
Were you given information or offered advice from a health professional about contraception?
	2013		2015
	% (n=2,295)	Confidence Interval	% (n=1,991)	Confidence Interval
Yes	92	(91.5 , 93.4)	95	(94.1 , 95.9)
No	8	(6.6 , 8.5)	5	(4.1 , 5.9)

4.44 However, there was a decrease in the number of women who said that they definitely received help and advice about their baby's health and progress (74% compared to 78%) with over one in four women saying only to some extent or that they did not receive this help and advice. More women said that they received this help and advice in NHS Dumfries & Galloway (81%) compared to NHS Forth Valley and NHS Borders (63% and 66% respectively). Sixty seven per cent of women said they definitely received help and advice about feeding their baby with one third of women saying only to some extent or no (Table 37).

Table 37. Advice on infant feeding and health

In the six weeks after the birth of your baby did you receive help and advice from health professionals about your baby's health and progress?
	2013		2015
	% (n=2,241)	Confidence Interval	% (n=1,999)	Confidence Interval
Yes, definitely	78	(76.4 , 79.5)	74	(72.2 , 75.8)
Yes, to some extent	20	(18.5 , 21.6)	24	(22.6 , 26.2)
No	2	(1.5 , 2.5)	2	(1.1 , 2.1)
In the six weeks after the birth of your baby did you receive help and advice from a midwife or health visitor about feeding your baby?
	2013		2015
	% (n=2,000)	Confidence Interval	% (n=1,840)	Confidence Interval
Yes, definitely	67	(65.5 , 69.3)	67	(64.5 , 68.6)
Yes, to some extent	26	(24.0 , 27.5)	26	(24.5 , 28.4)
No	7	(5.8 , 7.8)	7	(5.9 , 8.1)

4.45 Only 56% of women said that they were definitely given enough information about their own physical recovery after birth with one third saying only to some extent and 11% saying no (Table 38). Similarly, a substantial minority of women did not appear to be receiving enough information or advice about coping with emotional changes that might be experienced after the birth. Only 57% of women said that they were definitely given enough information and while 76% said that they were given advice about who to contact if they needed advice about emotional changes that they might experience almost one in four women were not given this advice. Women in NHS Highland were more likely to receive this type of information than women in NHS Forth Valley.

Table 38. Information about mother's health and wellbeing

Were you given enough information about your own physical recovery after the birth?
	2013		2015
	% (n=2,299)	Confidence Interval	% (n=1,988)	Confidence Interval
Yes, definitely	64	(62.5 , 66.0)	56	(53.5 , 57.6)
Yes, to some extent	28	(26.5 , 29.7)	33	(31.3 , 35.2)
No	8	(6.6 , 8.6)	11	(9.9 , 12.5)
Were you given enough information about any emotional changes you might experience after the birth?
	2013		2015
	% (n=2,197)	Confidence Interval	% (n=1,926)	Confidence Interval
Yes, definitely	59	(57.1 , 60.8)	57	(54.8 , 58.9)
Yes, to some extent	30	(28.5 , 31.9)	32	(30.3 , 34.2)
No	11	(9.6 , 12.0)	11	(9.6 , 12.2)
Were you told who you could contact if you needed advice about emotional changes you might experience after the birth?
			2015
			% (n=1,783)	Confidence Interval
Yes			76	(74.5 , 78.2)
No			24	(21.8 , 25.5)

Rating of postnatal care at home

4.46 Overall 58% of women rated their postnatal care at home as excellent with a further 33% saying their care was good.

Chart 4 - Overall rating of postnatal care at home

What women said about their care at home after the birth

4.47 There were 535 comments in this section representing around 26% of the overall survey sample. Comments were balanced between positive and negative observations of the care received. As in antenatal care, continuity of care emerges as a major theme. A second major theme in this section relates to support for infant feeding, referring both to breast and formula feeding. Other themes are recovery and adjustment of mothers including a very small number of comments on fathers' adjustment.

Continuity and Consistency of Care

4.48 Almost one quarter of the comments are concerned with the continuity and consistency of care received. Some women have commented that they were generally happy with their care despite seeing a number of midwives and health professionals postnatally.

'I saw a different midwife at each visit but they were all lovely and helpful'.

4.49 However the majority of the comments concerning continuity do highlight problems with a lack of consistency and continuity in the postnatal care received at home. A lack of 'informational continuity' is a focus of concern, with women finding it tiring to have to repeat their information or concerning that the professionals caring for them did not appear to be aware of their particular circumstances.

'I saw a different midwife every time out of my [number removed] visits. All had different opinions which, as an emotional first time mum, is not helpful because it can be confusing and frustrating'.

4.50 A number of women commented that a lack of consistent advice and support with breastfeeding postnatally had been negative for them.

'Seeing different [number removed] midwives at home after giving birth meant I did not get consistent advice regarding breastfeeding. Nor did they take into account my previous experience'.

'Midwives were excellent, but I never saw the same midwife twice - it was a different midwife every time. I was recovering from surgery, had problems with my wound, it would have been beneficial to see the same midwife'.

4.51 On the other hand, experience of 'relationship continuity' in their postnatal care is generally described in extremely positive terms within the postnatal comments.

'Received fantastic care. Midwife seen me several times after I developed an infection. She always dedicated a long time at visits and gave me lots of great advice'.

'Named Midwife'

4.52 Some women commented specifically on their 'named midwife'. Others talked about 'my midwife' which may have designated the significance of the professional relationship that had developed through continuity of care, rather than an awareness of the 'named midwife' policy.

'The named midwife I was given was brilliant. She took time with myself and partner and baby when born. She also listened to everything we had to say. She became a friend. Only time I didn't have her was her days off or holidays'.

4.53 Some women would have liked to see their 'named midwife' postnatally but were not given the opportunity to do so.

'Would have liked to have seen my named midwife after the birth instead of 3 different ones'.

Continuity of Antenatal and Postnatal Care

4.54 A number of women chose to comment on the continuity of community based maternity care they had received from midwives during both the antenatal and postnatal periods. Comments were particularly positive about seeing the same midwife throughout.

'Very positive experience seeing the same midwife as antenatal care'.

4.55 There were also comments from women who had not seen the midwife they had been under during pregnancy but would have liked to do so, or felt that it would have been better for their care and outcomes had it been possible.

'I wish I could have seen the midwife who gave me antenatal care at home after my baby was born because we had developed a rapport during my pregnancy. However the 3 or 4 different midwives who visited me at home were lovely and very helpful'.

Team Midwifery

4.56 Much as in the antenatal section, a minority of comments in the community postnatal section indicate that women had experienced very good continuity in their care through a community team approach, sometimes under the same team of midwives who had cared for them during pregnancy.

'The midwives and breast feeding support worker were excellent. I saw the same two or three midwives and they had obviously discussed things in advance, so I was not having to repeat things'.

'Advice was consistent and supportive, regardless of which midwife I saw'.

Health Visitors

4.57 A small number of women commented about the relationship they had developed with a health visitor or health visiting team since the birth of their baby.

'Health visitor still continues to visit me and my baby since birth, but this is due to the start baby had. Very supportive'.

'Health visitor was an excellent support and continues to be'.

Feeding Choices and Support

4.58 A large number of the comments in this section refer to women's choice of how to feed their babies and how this was supported by the health professionals they saw during this period. Around three quarters of the comments referred negatively to breast feeding support or feeding support more generally, with around a quarter of the comments expressing satisfaction with breastfeeding support, many women indicating they had really needed this in order to continue breastfeeding their babies.

'Particularly the support with breast feeding was excellent. This is by far the hardest thing I've ever done and would have thrown in the towel had it not been for the support and encouragement from the midwives and health visitors'.

'I was contacted by the breastfeeding support team who offered a home visit which I accepted. This was invaluable and really appreciated. It helped with my confidence for feeding my baby. I have since had follow-up calls to check I'm OK and to see if they can support me further'.

4.59 However, quite a few women took the time to comment that they had experienced great pressure to breastfeed and were unhappy about this. Other women felt judged, unsupported and uninformed in their decision to formula feed their babies.

'The hard sell on "breast in best" is very annoying if you've not been able to breastfeed even though you tried'.

'I feel the pressure put on you to continue breastfeeding, even when expressing strong feelings about wanting to stop, is far too much. It made me feel uncomfortable to talk to midwife about it'.

4.60 Of the women who commented negatively about the breastfeeding support that was available or offered to them postnatally, the main issues highlighted were feeling they had not had the right support to allow them to continue with breastfeeding, that the advice offered had been unrealistic, inconsistent or confusing, or that there was a lack of specialist breastfeeding support local to them.

'The midwives in my area are doing excellent jobs but do not have the time to spend a lot of time helping with feeding problems. Lactation consultants urgently needed in this area!'

'Regular visits, however inconsistent advice regarding breastfeeding, which was poor. Very little hands-on practical feeding support, could have done with this to try different positions'.

Infant Health: Advice, Support and Healthcare

4.61 A number of women commented about their baby's health in the early days, and the care and advice they received in relation to this. Some comments described dissatisfaction with the level of care and attention they had received in relation to their babies' health and wellbeing, while others felt that they needed more reassurance or information regarding the health and care of their babies.

'Not enough help given when my child lost too much weight. Wasn't given advice till we went into hospital. Felt I supposed to know what I was doing because I had a child already (health visitors)'.

'I felt like I should have been visited more. My baby was small when born. I would have liked more reassurance she was OK'.

Maternal Recovery and Adjustment

4.62 Almost one in five of the comments in this section related to women's own health and adjustment following the birth. A number of women commented that the aftercare and information they received in the community was not helpful or sufficient.

'I think it's misunderstood how long it takes to recover after a section. I sometimes had the feeling health professionals think you should be recovered after the 6 week mark. Only after talking to other mums I realised we were all still on the painkillers!'

'The postnatal care following an emergency C-section seemed too short. I saw my consultant a couple of times which was good. I felt I was discharged from hospital too soon….I would have liked more advice on scar healing'.

4.63 Several women had felt unprepared for how they would feel following the birth, and how long it would take to recover physically.

'I was shocked at how long my physical recovery took. A bit more info, explaining that it can take a long time to physically heal, would have been good'.

4.64 Others felt that their own health came second to their babies' needs postnatally.

'I feel breastfeeding was encouraged to the detriment of my own physical health'.

4.65 Several women felt their mental and emotional health needs had not been met by the postnatal care they received.

'I seriously struggled emotionally and tried to hide it, no-one picked up on it - just said I looked great as had lost weight so quickly'.

Quality and Quantity of Community Postnatal Care

4.66 There were a number of comments from women about how they have felt about the postnatal care they have received following discharge from hospital. These concern both the 'quantity' of the care in terms of how many visits, when these took place, and how long clinical involvement with their family continued, and the 'quality' of the care experienced. Some women expressed gratitude that a midwife or health visitor appeared at their door on a regular basis in the early days at home with their baby

'I found it very reassuring to have visits from both the midwives and health visitors after my baby was born'.

4.67 Although not all women felt that postnatal visits were necessary.

'Midwife home visits should be optional, as I just wanted to get in a routine and I had done it all before'

4.68 The time available for postnatal visits or appointments was also commented upon by respondents, suggesting that women were aware that their midwives and health visitors were under pressure, and that visits could feel rushed as a result. Or health professionals could instead be experienced as having time for women and their babies despite pressures of work. Some women would have preferred to know more specifically when the midwife would call.

'I always felt that the midwife or health visitor who came to see me at home, had lots of time for me. They listened to everything and I never felt rushed whist talking with them or when they checked over my baby. I really appreciated that as I know they are very busy'.

'Midwives did not give time that they would come, so had to wait in all day, but the health visitor did and was much better'.