Client-centered flexible planning of home-based postpartum care: A randomized controlled trial on the quality of care.

BACKGROUND: Standardization of health systems often hinders client-centered care. This study investigates whether allowing more flexibility in the planning range of the Dutch home-based postpartum care service improves its quality of care, as innovative approach to client-centered care. METHODS: A randomized controlled trial was conducted (2017-2019), in which pregnant women who intended to breastfeed were assigned into two groups (1:1). The intervention group was allowed to receive care up to the 14th-day postpartum, instead of the first 8-10 consecutive days ("usual care"). Primary outcome measure was the proportion of newborns still receiving exclusively breastmilk on final caring day of the service. This so-called successful breastfeeding rate is currently used by the Dutch health sector to measure the quality of care. Secondary outcome measures were self-care experience, overall care experience, and exclusive breastfeeding duration rate. RESULTS: Based on data from 1275 participants, there was no difference in exclusive breastfeeding on final caring day (86,7% intervention group vs. 88,9% control group, RR: 1.03, 95% CI: 0.98-1.07). Both groups showed similar self-care experiences. Women in the intervention group had slightly poorer overall care experience and lower exclusive breastfeeding duration rates. CONCLUSIONS: This study found no effect on the quality of care when allowing more flexibility in the planning range of home-based postpartum care. Women can, therefore, be offered more flexibility to suit them. Given the confusion in interpreting the sector's current main quality indicator, we call for an inclusive dialogue on how to best measure the quality of home-based postpartum care.

Mothers' experiences of client-centred flexible planning in home-based postpartum care: A promising tool to meet their diverse and dynamic needs.

OBJECTIVE: To explore mothers' perspectives and experiences when facilitating greater flexibility in the planning range of home-based postpartum care, as an innovative tool to more client-centred care. DESIGN: A qualitative study design with semi-structured in-depth interviews. SETTING: The study was executed in collaboration with a postpartum care organisation in the Netherlands. It was part of a larger research project that studied the health effects of a new way of planning home-based postpartum care. This so-called 'flexible planning' made spreading and pausing of care possible up to the 14th day postpartum instead of the standard care planning up to the 8th day postpartum. PARTICIPANTS: Mothers eligible to be interviewed for this study were participants of the larger research project who were allowed to plan their care according to the flexible planning. Twenty-one mothers were recruited through purposive sampling, of which ten were first-time mothers. FINDINGS: Mothers valued the flexible planning as the timing of care could be tailored to their personal preferences and contexts. Yet, two main challenges were found: 1. mothers experienced difficulties in communicating and translating their dynamic needs into a care planning and 2. they felt discomfort in assigning tasks to care workers. Besides, our findings showed that care workers' practical as well as their emotional support (i.e. 'doing' vs. 'being') are greatly important in responding to mothers' needs. KEY CONCLUSIONS: A flexible planning is a promising tool to facilitate more client-centred care in the postpartum care period. Yet, the hectic and overwhelming nature of the first few postpartum days can complicate the forward planning of care. In addition, not knowing what to expect from the postpartum care period and having a main focus on care workers 'doing' can lead to unclear and undesired working relations. IMPLICATIONS FOR PRACTICE: When planning care in practice, a dialogue should be held between care workers and parents in which both their fields of expertise are respected. Above all, our study elucidated that novel care innovations like ours need to be co-created directly from the start with all involved parties to truly be successful.

Maternal self-care in the early postpartum period: An integrative review.

OBJECTIVE: To clarify the concept of maternal self-care in the early postpartum period and to develop a conceptual framework of mothers' self-care needs. DESIGN: An integrative review concept analysis method was used as described by Whittemore and Knafl (2005). As part of this data analysis process, a matrix based on Orem's self-care theory was developed to facilitate a structured and systematic analysis of the data. DATA SOURCES: CINAHL, Embase, PubMed, and Web of Science. REVIEW METHODS: After systematic and rigorous literature searches, the title and abstract of 1535 studies were scanned while applying five exclusion criteria. This resulted in 29 studies for full text review. Eventually, nine studies were appraised by two quality assessment tools and selected for the analysis. RESULTS: Guided by Orem's self-care theory, we have built a conceptual framework that depicts maternal self-care in the early postpartum period. Mothers' self-care needs involve numerous and diverse activities, tasks, and emotions, which can be categorised into three themes: universal, developmental, and health self-care needs. Their ability to perform these needs is subjected to various internal and external factors as well as the societal context they live in. CONCLUSIONS: Our review indicated that maternal self-care needs, already in the first few days postpartum, go beyond mothers' physical health as it extends to their emotional well-being as well. Postpartum care is, however, generally centred around physical self-care needs putting mothers' emotional self-care needs at risk of neglection. Further research is needed to determine how individualised care innovations can promote maternal self-care.

The unintended consequences of client-centred flexible planning in home-based postpartum care: a shift in care workers' tasks and responsibilities.

OBJECTIVE: To explore care workers' experiences with a flexible planning of home-based postpartum care as an innovative instrument to facilitate more client-centred care. DESIGN: A mixed-methods design with a primarily qualitative approach followed by a quantitative follow-up, according to the Priority-Sequence model. SETTING: This study is part of a larger research project researching the health effects of a flexible planning in postpartum care. The new planning enables clients and care workers to spread and/or pause the care over 14 days postpartum instead of the standard planning of eight to ten consecutive days. PARTICIPANTS: Maternity home care workers who provide care according the flexible planning. Eight care workers were interviewed, another eight care workers participated in the focus group discussion, and 59 care workers filled in the survey. FINDINGS: Two main unintended consequences of the flexible planning were found: 1. care workers experienced an undesirable 'shift in their tasks' along the course of the postpartum period and 2. were heavily worried about 'making enough contracted hours'. Consequently, care workers unwillingly performed much more domiciliary activities compared to the standard planning, especially during the final days of care. KEY CONCLUSIONS: The predominant nursing tasks and responsibilities of care workers appeared insufficient to respond to clients' altering needs. In addition, shorter working days and on-call duties caused an undesired excessive high-level of flexibility among care workers. Consequently, care was paradoxically determined by organisational structures rather than clients' individual needs. IMPLICATIONS FOR PRACTICE: Our study elucidated that co-creation together with health professionals is a prerequisite for successfully implementing innovations as their way of working and personal lives are profoundly affected.

Maternity care and Human Rights: what do women think?

BACKGROUND: A human rights approach to maternal health is considered as a useful framework in international efforts to reduce maternal mortality. Although fundamental human rights principles are incorporated into legal and medical frameworks, human rights have to be translated into measurable actions and outcomes. So far, their substantive applications remain unclear. The aim of this study is to explore women's perspectives and experiences of maternal health services through a human rights perspective in Magu District, Tanzania. METHODS: This study is a qualitative exploration of perspectives and experiences of women regarding maternity services in government health facilities. The point of departure is a Human Rights perspective. A total of 36 semi-structured interviews were held with 17 women, between the age of 31 and 63, supplemented with one focus group discussion of a selection of the interviewed women, in three rural villages and the town centre in Magu District. Data analysis was performed using a coding scheme based on four human rights principles: dignity, autonomy, equality and safety. RESULTS: Women's experiences of maternal health services reflect several sub-standard care factors relating to violations of multiple human rights principles. Women were aware that substandard care was present and described a range of ways how the services could be delivered that would venerate human rights principles. Prominent themes included: 'being treated well and equal', 'being respected' and 'being given the appropriate information and medical treatment'. CONCLUSION: Women in this rural Tanzanian setting are aware that their experiences of maternity care reflect violations of their basic rights and are able to voice what basic human rights principles mean to them as well as their desired applications in maternal health service provision.