"But at home, with the midwife, you are a person": experiences and impact of a new early postpartum home-based midwifery care model in the view of women in vulnerable family situations.

BACKGROUND: Postpartum home-based midwifery care is covered by basic health insurance in Switzerland for all families with newborns but must be self-organized. To ensure access for all, Familystart, a network of self-employed midwives, launched a new care model in 2012 by ensuring the transition from hospital to home through cooperation with maternity hospitals in the Basel area. It has particularly improved the access to follow-up care for families in vulnerable situations needing support beyond basic services. In 2018, the SORGSAM (Support at the Start of Life) project was initiated by Familystart to enhance parental resources for better postpartum health outcomes for mothers and children through offering improved assistance to psychosocially and economically disadvantaged families. First, midwives have access to first-line telephone support to discuss challenging situations and required actions. Second, the SORGSAM hardship fund provides financial compensation to midwives for services not covered by basic health insurance. Third, women receive financial emergency support from the hardship fund. AIM: The aim was to explore how women living in vulnerable family situations experienced the new early postpartum home-based midwifery care model provided in the context of the SORGSAM project, and how they experienced its impact. METHODS: Findings are reported from the qualitative part of the mixed-methods evaluation of the SORGSAM project. They are based on the results of seven semi-structured interviews with women who, due to a vulnerable family postpartum situation at home, received the SORGSAM support. Data were analyzed following thematic analysis. RESULTS: Interviewed women experienced the early postpartum care at home, as "relieving and strengthening" in that midwives coordinated patient care that opened up access to appropriate community-based support services. The mothers expressed that they felt a reduction in stress, an increase in resilience, enhanced mothering skills, and greater parental resources. These were attributed to familiar and trusting relationships with their midwives where participants acknowledged deep gratitude. CONCLUSION: The findings show the high acceptance of the new early postpartum midwifery care model. These indicate how such a care model can improve the well-being of women in vulnerable family situations and may prevent early chronic stress in children.

Communication barriers in maternity care of allophone migrants: Experiences of women, healthcare professionals, and intercultural interpreters.

AIM: To describe communication barriers faced by allophone migrant women in maternity care provision from the perspectives of migrant women, healthcare professionals, and intercultural interpreters. BACKGROUND: Perinatal health inequality of migrant women hinges on barriers to services, with a major barrier being language. Their care is often also perceived as demanding due to conflicting values or complex situations. Potentially divergent perceptions of users and providers may hinder efficient communication. DESIGN: Qualitative explorative study. METHODS: A convenience sample of 36 participants was recruited in the German speaking region of Switzerland. The sample consisted of four Albanian and six Tigrinya speaking women, 22 healthcare professionals and four intercultural interpreters (March-June 2016) who participated in three focus group discussions and seven semi-structured interviews. Audio recordings of the discussions and interviews were transcribed and thematically analysed. RESULTS: The analysis revealed three main themes: the challenge of understanding each other's world, communication breakdowns and imposed health services. Without interpretation communication was reduced to a bare minimum and thus insufficient to adequately inform women about treatment and address their expectations and needs. CONCLUSION: A primary step in dismantling barriers is guaranteed intercultural interpreting services. Additionally, healthcare professionals need to continuously develop and reflect on their transcultural communication. Institutions must enable professionals to respond flexibly to allophone women's needs and to offer care options that are safe and in accordance to their cultural values. IMPACT: Our results give the foundation of tenable care of allophonic women and emphasize the importance of linguistic understanding in care quality.

Barrier-free communication in maternity care of allophone migrants: BRIDGE study protocol.

AIM: To describe communication and access barriers encountered by allophone women of different migration backgrounds in the Swiss maternity care services, from the perspective of users, healthcare professionals and intercultural interpreters. BACKGROUND: In addition to the challenges of maternal adjustment, pregnant migrant women must also deal with an unfamiliar health service system. Some must overcome language barriers and the stress of uncertain residence status. Limited access to maternity care increases perinatal morbidity and mortality. Almost 10% of foreigners speak none of Switzerland's official languages. Factors that facilitate or hinder communication between migrant women and perinatal healthcare professionals are under-studied and must be understood if we are to overcome those barriers in clinical practice. DESIGN: Qualitative exploratory study with quantitative sub-study. METHODS: Participants will be drawn from German to speaking regions of Switzerland. We will conduct focus group discussions and semi-structured interviews with users in their own language (Albanian and Tigrinya) and with healthcare professionals and intercultural interpreters (March-June 2016), then perform Thematic Analysis on the data. In the sub-study, midwives will report their experience of using a telephone interpreting service during postnatal home visits in a questionnaire (October 2013-March 2016). Data will be analysed with descriptive statistics. DISCUSSION: Our study will reveal patterns in communications between allophone migrant women and healthcare providers and communication barriers. By incorporating multiple perspectives, we will describe the challenges all parties face. Our results will inform those who draft recommendations to improve provision of maternity care to allophone women and their families. TRIAL REGISTRATION: ClinicalTrials.gov ID: BernUAS NCT02695316.

Does Coordinated Postpartum Care Influence Costs?

QUESTIONS UNDER STUDY: To investigate changes to health insurance costs for post-discharge postpartum care after the introduction of a midwife-led coordinated care model. METHODS: The study included mothers and their newborns insured by the Helsana health insurance group in Switzerland and who delivered between January 2012 and May 2013 in the canton of Basel Stadt (BS) (intervention canton). We compared monthly post-discharge costs before the launch of a coordinated postpartum care model (control phase, n = 144) to those after its introduction (intervention phase, n = 92). Costs in the intervention canton were also compared to those in five control cantons without a coordinated postpartum care model (cross-sectional control group: n = 7, 767). RESULTS: The average monthly post-discharge costs for mothers remained unchanged in the seven months following the introduction of a coordinated postpartum care model, despite a higher use of midwife services (increasing from 72% to 80%). Likewise, monthly costs did not differ between the intervention canton and five control cantons. In multivariate analyses, the ambulatory costs for mothers were not associated with the post-intervention phase. Cross-sectionally, however, they were positively associated with midwifery use. For children, costs in the post-intervention phase were lower in the first month after hospital discharge compared to the pre-intervention phase (difference of -114 CHF [95%CI -202 CHF to -27 CHF]), yet no differences were seen in the cross-sectional comparison. CONCLUSIONS: The introduction of a coordinated postpartum care model was associated with decreased costs for neonates in the first month after hospital discharge. Despite increased midwifery use, costs for mothers remained unchanged.

Safe start at home: what parents of newborns need after early discharge from hospital - a focus group study.

BACKGROUND: The length of postpartum hospital stay is decreasing internationally. Earlier hospital discharge of mothers and newborns decreases postnatal care or transfers it to the outpatient setting. This study aimed to investigate the experiences of new parents and examine their views on care following early hospital discharge. METHODS: Six focus group discussions with new parents (n = 24) were conducted. A stratified sampling scheme of German and Turkish-speaking groups was employed. A 'playful design' method was used to facilitate participants communication wherein they used blocks and figurines to visualize their perspectives on care models The visualized constructions of care models were photographed and discussions were audio-recorded and transcribed verbatim. Text and visual data was thematically analyzed by a multi-professional group and findings were validated by the focus group participants. RESULTS: Following discharge, mothers reported feeling physically strained during recuperating from birth and initiating breastfeeding. The combined requirements of infant and self-care needs resulted in a significant need for practical and medical support. Families reported challenges in accessing postnatal care services and lacking inter-professional coordination. The visualized models of ideal care comprised access to a package of postnatal care including monitoring, treating and caring for the health of the mother and newborn. This included home visits from qualified midwives, access to a 24-h helpline, and domestic support for household tasks. Participants suggested that improving inter-professional networks, implementing supervisors or a centralized coordinating center could help to remedy the current fragmented care. CONCLUSIONS: After hospital discharge, new parents need practical support, monitoring and care. Such support is important for the health and wellbeing of the mother and child. Integrated care services including professional home visits and a 24-hour help line may help meet the needs of new families.

[Young first-time parents' experiences with family-centred postpartal health care in Switzerland]. / Erfahrungen junger Eltern mit der familienzentrierten Betreuung in der Primärversorgung in der Schweiz: Eine qualitative Evaluationsstudie.

BACKGROUND: Routine postnatal care normally addresses only the mother and her child. In Switzerland, counselling for all parents and their children is provided by family nurses in a community-based health care setting. We implemented a new approach to ensure father involvement within the framework of the Calgary Family Assessment (CFAM) and the Calgary Intervention Model CFIM of Wright and Leahey (2013) in the northwest of Switzerland. AIM: This qualitative study explored how mothers and fathers experienced the newly developed family-centred consultation. METHOD: Data collection was performed by means of participant observation and semi- structured interviews with a sample of five first-time parents with healthy neonates. Data were analysed by using content analysis according to Mayring. RESULTS: Mothers and fathers experienced family-centred consultation as effective. They felt more secure and confident "to handle the new situation" and obtained trustful, concrete and professional support to take care of their baby, particularly with regard to breast feeding, crying and sleeping patterns. CONCLUSIONS: Fathers felt included into postnatal care from the beginning. Family nursing offers a useful framework for family-centred postnatal health care.

[What women want: a qualitative study about postnatal midwifery care at home]. / Was Wöchnerinnen wünschen: Eine qualitative Studie zur häuslichen Wochenbettbetreuung nach der Spitalentlassung durch frei praktizierende Hebammen.

In Switzerland, decreases in regular hospital treatment after birth are leading increasingly to mother and child being cared for at home by independent midwives. The research herein was carried out in order to understand the needs of mothers in their home once they leave the hospital and what this midwife provided care consists of. In 2008, eight women from central Switzerland were interviewed on two separate occasions after the birth of their child, and the interviews were analysed using content analysing techniques. Mothers explained that they wanted their baby and themselves to be well cared for. They needed rest and support for recuperation and wished to spend quality time with their new family. The midwifes assisted the mothers to fulfil their needs by counselling, by instructing and by giving information, but they rarely encouraged them to be together as a family. The relationship between midwife and mother turned out to be an important support. Mothers were satisfied if mutual trust was built and if the midwife perceived their needs, respected their autonomy and took the time to be with them. Midwives contribute to the basic well-being of families and support women with medical expertise and ongoing care. Furthermore families need support in general household issues so that new mothers can recover sufficiently.

Responding to a crying infant - you do not learn it overnight: a phenomenological study.

OBJECTIVE: to examine the views and practices of first-time and experienced mothers in response to infant crying during the first 12 weeks post birth. DESIGN: longitudinal, qualitative study using an interpretive, phenomenological approach. SETTING: postnatal hospital and home settings in Switzerland. PARTICIPANTS: maximum variation sampling of 15 new mothers of diverse parity and educational background who had given birth to a full-term healthy neonate. METHODS: participant observations in the postnatal ward and two narrative interviews at participants' homes at 6-8 and 12-14 weeks post partum. Data analysis used interpretive approaches of case analysis, thematic analysis and exemplars. FINDINGS: first-time mothers showed some soothing skills from the beginning, but fine-tuned their practices of handling the crying infant and managing their own reactions. With growing experience mothers acquired a differentiated understanding of the crying's reason and urgency and used more successful soothing techniques. At the same time they learned to assess and mitigate their own stress reactions by self-soothing and adopting realistic expectations of normal infant behaviour. Experienced mothers knew the infant's frequent crying would diminish after a while whereas first-time mothers coped without this positive expectation. KEY CONCLUSIONS: with increasing child-care experience mothers' skills and attitudes towards crying changed, leading to a calmer and less escalating response to their crying infant. IMPLICATIONS FOR PRACTICE: inexperienced mothers need information on neonatal crying behaviour and on parents' stress response. They should be taught how to recognise and respond to the new-born's signals, and how to cope with their own stress. Postnatal care should provide novice mothers to learn from experienced role models.

Predictors of early postpartum mental distress in mothers with midwifery home care--results from a nested case-control study.

PRINCIPLES: The prevalence of early postpartum mental health conditions is high. Midwives and other health professionals visiting women at home may identify mothers at risk. This seems crucial given decreasing trends of length of hospital stay after childbirth. This study aimed to identify predictors of maternal mental distress in a midwifery home care setting. METHODS: Using the statistical database of independent midwives' services in Switzerland in 2007, we conducted a matched nested case-control study. Out of a source population of 34,295 mothers with midwifery home care in the first ten days after childbirth, 935 mothers with maternal distress and 3,645 controls, matched by midwife, were included. We analysed whether socio-demographic, maternal and neonatal factors predict maternal mental distress by multivariable conditional logistic regression analysis. RESULTS: Infant crying problems and not living with a partner were the strongest predictors for maternal distress, whereas higher parity was the most protective factor. Significantly elevated risks were also found for older age, lower educational levels, breast/breastfeeding problems, infant weight gain concerns, neonatal pathologies and use of midwifery care during pregnancy. A lower likelihood for maternal distress was seen for non-Swiss nationality, full-time employment before birth, intention to return to work after birth and midwife-led birth. CONCLUSION: The study informs on predictors of maternal mental distress identified in a home care setting in the early postpartum period. Midwives and other health care professionals should pay particular attention to mothers of excessively crying infants, single mothers and primipara, and assess the need for support of these mothers.

[Paradise lost - Reflexion of preterm birth from the perspective after a brain injury. A case study]. / Das verlorene Paradies - Reflexion der Frühgeburt aus Anlass eines Schädel-Hirn-Traumas. Eine Fallstudie.

This case study describes the history of an older person, born in 1942 preterminally, who suffered from a brain injury in 2005. Problems in rehabilitation elicited the search for a new meaning in life. In analysing and interpreting the brain injury, preterm birth played a crucial role. The theme of lifelong compensation of deficits, caused by preterm birth, gained new importance. The consequences of brain injury left unsuccessful his former modes of compensation. He was confronted with finding new strategies in order to counterbalance the growing decompensation. This report is based on and was developed through respect for the principles of user involvement in research.

Crying babies, tired mothers: what do we know? A systematic review.

OBJECTIVE: to synthesise the evidence on the interconnectedness of infant crying and maternal tiredness in the postpartum period, both from quantitative as well as from qualitative studies. METHODS: a systematic review was conducted including studies in English, French and German published from 1980 to 2007. Studies were included in the systematic review if they had extractable data on infant crying as well as maternal tiredness in the period of 0-3 months post partum. Of 100 retrieved publications, 10 met these criteria. FINDINGS: evidence from this review indicated that the amount of infant crying during the first three months postpartum is associated with the experience of tiredness and fatigue in new mothers. Significant associations were found in five of six quantitative studies. The four identified qualitative studies describe how infant crying disrupts new mothers' circadian rhythms, reducing opportunities to rest and exacerbating tiredness. Incremental exhaustion diminished parents' ability to concentrate, raising the fear of harming their children, triggering depressive symptoms and burdening parent-child interaction. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: if healthcare professionals are to address the prominent concerns of parents caring for a neonate, it is essential to review current care practices and tailor them to maternal and infant needs. A care strategy alleviating the burden of infant crying and maternal fatigue has the potential to strengthen family health from the earliest stage.

Reproductive health care for asylum-seeking women - a challenge for health professionals.

BACKGROUND: Dealing with pregnancy, childbirth and the care of newborn babies is a challenge for female asylum seekers and their health care providers. The aim of our study was to identify reproductive health issues in a population of women seeking asylum in Switzerland, and to examine the care they received. The women were insured through a special Health Maintenance Organisation (HMO) and were attending the Women's Clinic of the University Hospital in Basel. We also investigated how the health professionals involved perceived the experience of providing health care for these patients. METHODS: A mixed methods approach combined the analysis of quantitative descriptive data and qualitative data obtained from semi-structured interviews with health care providers and from patients' files. We analysed the records of 80 asylum-seeking patients attending the Women's Clinic insured through an HMO. We conducted semi-structured interviews with 10 care providers from different professional groups. Quantitative data were analysed descriptively. Qualitative data analysis was guided by Grounded Theory. RESULTS: The principal health problems among the asylum seekers were a high rate of induced abortions (2.5 times higher than in the local population), due to inadequate contraception, and psychosocial stress due to the experience of forced migration and their current difficult life situation. The language barriers were identified as a major difficulty for health professionals in providing care. Health care providers also faced major emotional challenges when taking care of asylum seekers. Additional problems for physicians were that they were often required to act in an official capacity on behalf of the authorities in charge of the asylum process, and they also had to make decisions about controlling expenditure to fulfil the requirements of the HMO. They felt that these decisions sometimes conflicted with their duty towards the patient. CONCLUSION: Health policies for asylum seekers need to be designed to assure access to adequate contraception, and to provide psychological care for this vulnerable group of patients. Care for asylum seekers may be emotionally very challenging for health professionals.

Predictors of crying problems in the early postpartum period.

OBJECTIVE: To investigate maternal and infant factors associated with midwife-reported crying problems in the early postpartum period. DESIGN: Case control study. SETTING: Postnatal home care in Switzerland. PARTICIPANTS: Seven thousand seven hundred and sixty-five mother/child dyads who received postnatal homecare by midwives (n=1,636 cases of midwife-reported crying problems, n=6,129 controls). METHODS: We investigated factors associated with infant crying problems during the postpartum period as documented in the Statistical Database of Independent Midwives' Services in Switzerland (2007). Using case control methodology, we matched all identified cases of crying problems with controls who had been cared for by the same midwife. A conditional logistic regression model was used to analyze the associations of reported crying problems with maternal and infant factors. RESULTS: Maternal health and mood problems in the immediate postpartum period were significantly associated with reported crying problems. Maternal health and mood problems included physical complications after birth, psychological decompensation, and depression. Further risk factors for infant crying problems were planned resumption of paid work directly after paid maternity leave (at 15-16 weeks postpartum) and immigrant status. A protective effect was observed for higher parity. CONCLUSIONS: Crying problems in the early postpartum period are associated with mothers' physical, psychological, and social conditions. Care practices that promote new mothers' physical and psychological recovery after birth could be a promising strategy to prevent early crying problems. Specific support is important for mothers with early signs of depression or decompensation, intention to return early to paid work, immigrant background, and for first-time mothers.

Crying babies, tired mothers - challenges of the postnatal hospital stay: an interpretive phenomenological study.

BACKGROUND: According to an old Swiss proverb, "a new mother lazing in childbed is a blessing to her family". Today mothers rarely enjoy restful days after birth, but enter directly into the challenge of combining baby- and self-care. They often face a combination of infant crying and personal tiredness. Yet, routine postnatal care often lacks effective strategies to alleviate these challenges which can adversely affect family health. We explored how new mothers experience and handle postnatal infant crying and their own tiredness in the context of changing hospital care practices in Switzerland. METHODS: Purposeful sampling was used to enroll 15 mothers of diverse parity and educational backgrounds, all of who had given birth to a full term healthy neonate. Using interpretive phenomenology, we analyzed interview and participant observation data collected during the postnatal hospital stay and at 6 and 12 weeks post birth. This paper reports on the postnatal hospital experience. RESULTS: Women's personal beliefs about beneficial childcare practices shaped how they cared for their newborn's and their own needs during the early postnatal period in the hospital. These beliefs ranged from an infant-centered approach focused on the infant's development of a basic sense of trust to an approach that balanced the infants' demands with the mother's personal needs. Getting adequate rest was particularly difficult for mothers striving to provide infant-centered care for an unsettled neonate. These mothers suffered from sleep deprivation and severe tiredness unless they were able to leave the baby with health professionals for several hours during the night. CONCLUSION: New mothers often need permission to attend to their own needs, as well as practical support with childcare to recover from birth especially when neonates are fussy. To strengthen family health from the earliest stage, postnatal care should establish conditions which enable new mothers to balance the care of their infant with their own needs.