Sample characteristics of participants
Our descriptive characteristics are based on the subsample of wave 2 participants (n=89) (interviewed 4-6 weeks post birth) who gave complete answers on questions regarding their access to support and care in the post-birth care period. As shown in Table
1, participants were slightly more likely to identify being of Aboriginal or visible minority background, and to have lower income and lower home ownership than the population in the study region [
42]. Participants had somewhat higher levels of high school completion compared to the local population. The lower income and home ownership of the sample is likely a reflection of their younger, childbearing age.
Participants’ median number of days in hospital was 2.4 days overall, and 1.9 days for persons reporting a vaginal birth; these findings support the literature noted earlier regarding a reduction in length of hospital stays following the birth of a child compared to earlier generations. While the demedicalisation of birth, as evidenced by short term hospital stays, may not in and of itself signal a lack of care in the post-birth period, coupled with the finding that approximately one third of participants (33.8%) reported that they desired post-birth care services that were not available, it is not clear that reductions in hospital stays have been accompanied by increases in community-based care options. The closed-ended data also show that greater proportion of participants with incomes below the median for the census region reported they would have liked post-birth care that was unavailable to them (39.5%) compared to participants with an income above the median (27.3%). The most commonly cited barriers to obtaining post birth support services included “cost” (42.8%) and “unavailability of home care supports” (38%).
As noted above, we asked participants to expand on the topic of access to post-birth care services, and barriers to receiving the care they wanted. The next section of the paper focuses on themes that emerged, both in terms of participants’ satisfaction with access to post-birth care, as well as lack of access to the services they wanted to help them through the early stages of being a new mother.
Qualitative analysis
Satisfaction with post-birth public services
Several participants either did not identify any additional post-birth care needs, or specifically described aspects of Canadian post-care services that contributed to a positive experience during the first six weeks of the birth of their baby. Most of these participants noted practitioners and services that contributed to quality continuity of care. Sarah,a age 27 and a mom for the third time, described her satisfaction with her maternity doctor’s team: “Just wonderful people, they’re just, they’re awesome. They really listen; they never treat me like an overactive, over-reactive mother. You know they always take my opinion very seriously and uh, they’re just really caring and really great.” Another participant, Annie, expressed gratitude for the public health nurse who visited her post-birth:
"The nurse contacted me right away when I got out of the hospital and she came to check up on me. [I]t’s kinda nice to know that they’ll come to you. [Because], you know, when you first get out of the hospital and especially after a C-section [you are] sore. You don’t really wanna go anywhere; you just wanna be home. So it’s nice to have that for them to come to you. (age 34; 1
st
child)"
Annie’s response addresses the importance of accessibility to health care during the post-birth period and having services available that are flexible to the needs and physical capacity of the new mother. Many participants mentioned positive aspects of post-birth care also highlighted easily-accessible helpful information. This included the 24-hour nurse hotline, which they saw as a beneficial support system for answering questions. Participants praised the workers of the hotline service as “knowledgeable” and “helpful” and easily accessible by phone.
Other participants discussed the benefit of having a midwife for their most recent child. Kathy explained:
"I went with the midwife this time round [and] I just felt that I was, I felt really, really well looked after […] it’s just so different having, you know, two women midwives where that’s all they do, versus the GP who does all kinds of things and doesn’t specialize in […] the amount of time, I think that’s a huge thing that they, the midwives, offer. (age 35; 2nd child)"
Another participant, Myra, highlighted that in addition to the more lengthy visits offered by midwives in comparison to physicians, an additional benefit was the availability of in home postpartum care and flexible appointment times:
"I can call them [the midwives] anytime and they will come over. Like it’s not even, it’s never a question like – if I ever needed to get in to see them now, like it was – they came here in the first two weeks and then I’ve been going there and if I needed to get in, I know they would just squeeze me in and - so that’s why I like it. (age 25; 2nd child)"
The dedicated time that the midwives’ spent on these participants as well as the flexibility with regard to service time and location were greatly valued in the post-birth period. The support and focus of midwifery care resulted in satisfactory continuity of care and specific support for the woman based on the midwives’ expertise. The qualities that made up a positive labour, delivery and post-birth experience were the same qualities addressed as absent from other participants’ post-birth experiences.
Dissatisfaction with post-birth services covered under the health care system
A major theme articulated by participants’ who expressed dissatisfaction with their interaction with the health care system was poor care during the labour and delivery period, and a lack of follow-up during the post-birth period. Concerning her hospital experience, Jessica stated:
"You really are like a number in the hospital. They’re, you don’t, they’re not a lot of caring women and I’m not sure whether it’s because they’re tired of their job, you know and they’re not happy that way or whether they’re just you know, but there were a couple of kind women there, you know […] you just, you don’t really get that attention that I really believe that you deserve and you need. (age 36; 3rd child)"
A second time mother, Lena, age 31, stated “I kinda (sic\ fell through the cracks a bit with this second baby… I don’t know what but nobody called me afterwards to remind me of things like shots and so I actually went, I went far too long before I got his shots.” Several respondents commented on a feeling that health care providers “did not pay attention, had a “million other things to do”, and that it would be beneficial if they could spend more time with the patient”.
Some participants identified a need for more emotional and social support services, in particular supports that were not connected to risk assessment activities. The desire for this type of support came from a variety of avenues, including health care professionals, mental health services and a space to informally socialize with other mothers. Kelsey, age 22 and a first time mom, expressed a desire to have a health care professional to confide in while her son was in the hospital that would not “potentially deem me ‘unfit’ to have my baby because I’m depressed or something […] that just scared me so I, I guess I had access to somebody to talk to but I didn’t use it because I felt it probably caused more trouble than I would have wanted.”
Women in Canada, including in the study area, are routinely screened for postpartum depression as part of public health care services [
43]. Using the Beck Depression Inventory, we found that 15% of participants at Wave 2 and 21% of participants at Wave 3 reported moderate depression symptoms [
44]. Some new mothers, such as Kelsey, who identify the need for mental health services during the post-birth period do not access the desired services because they are concerned that doing so will undermine the perception of competency and capacity to care for a child.
What women wanted and was not publicly available
As noted the above, thirty-four % of women wanted additional services than were provided via the health care system but were not available due to varying factors. Many of these women lacked a strong informal support system and the income to purchase post-care services out-of-pocket. Theresa, a first-time mother of twins, remarked:
"Well since I’ve been home like there have been times when having the two has just been really, really intense and really hard. I’m getting a grip on it now, but there were times within that first six weeks that I just felt like I was gonna lose my mind. It would be really nice if there was somehow just a number you could call, in the community, just to, I don’t know, like listen to you for a minute or, or, I don’t know, rush over and hold one of your babies! (age 30; 1
st
child)"
Sabina wished that the public health nurse would provide more continuous care during the initial weeks after the birth. But this is not a covered public care service in the study region, and as a result she had to go without:
"I would have liked the public nurse to come back again because she said she was going to and she didn’t because I had breastfeeding questions and you know he had that acne, that um, from breastfeeding and I didn’t, I didn’t, wasn’t sure whether that what it was or not. Just questions that you have. (age 30; 1
st
child) "
Three-quarters (74.7%) of the new mothers in our study reported that someone, primarily friends and family members, came forward to help them during the post-birth period; mothers appearing to be the most common source of informal. Without such care, they would have had to purchase it on the market, as Becky, age 33 and entering motherhood a second time, stated: “If, if I didn’t have my, my sister and mum, I definitely probably would consider a doula.” Other participants who wanted more post-birth care sought out a private doula, a service which is not publicly funded. Tina was able to pay for her doula, but saw it as an expense that she should not have to pay for:
"It would have been nice if the, you know, the doula. Like, we paid quite a bit for the doula. [Y]ou know it’s expensive uh, anyway it would be nice if there was um public health care. I think they’re worth it, it just like, it was something that we paid for and we knew wanted the support so but definitely it was expensive. (Age 24; 1
st
child)"
Other participants who did not have access to family care or the needed economic resources to pay for a doula went without. As Barb, age 23 and a 1st time mom, noted: “I would have liked a doula but they’re very expensive.”
Breastfeeding advice has become more commonplace in Canadian hospitals and all midwives are trained to routinely give such advice. At wave 2, 64.8% of new mothers were breastfeeding exclusively, but that drops to 50% at Wave 3. Eighty-nine per cent of the women reported problems with breastfeeding their infants at 3-6 weeks postpartum; At wave 3, 35% of them were still reporting breastfeeding problems. We asked the women who responded “yes” to having breastfeeding difficulties what sorts of difficulties they had. Some women had multiple problems at once, while others had one or two, and the level of severity of each source of difficulty also varied among participants. The most prominent of these were: sore nipples (the top source of difficulty), difficulty latching on, sleepy baby, and milk undersupply. Karli expressed her concerns about breastfeeding, stating:
"When we left the hospital I kinda worried because I still wasn’t, you know, breastfeeding that… My milk hadn’t come in and there was things like that so um. It was fine in the hospital cuz I had that support but once you go home you don’t have that support any longer. (age 31; 1
st
child)"
Other respondents similarly commented that “breastfeeding was the hardest” and that it would have been beneficial to have a lactation consultant who had time and expertise to devote specifically to the task. As these participants note, lactation consultation is a very important service as new mothers have a short window of time to establish breastfeeding before they may turn to bottle/formula feeding because they are worried that the baby is not being adequately nourished. The public health nurse visit may not be sufficiently timely or intensive enough to meet this important need. In fact, a lactation consultant is even a good addition to midwifery care in the first two weeks as the midwives help with breastfeeding but some people, particularly first time mothers, require more intensive support in early post-birth period. In our study only one-quarter (25.8%) of participants mentioned they had used the services of a lactation consultant in the post-birth care period.