Continuity of Care

The mothers’ narratives indicated a sense of embarking on a life journey that was at once exciting and daunting and which held not only promises of joy but also many unknowns, commencing with pregnancy and finishing with the birth of a baby. Along the way they expected to be cared for and supported by health professionals who would help them in their transition to motherhood. For example:

I was married for about six years when [baby] was born He was very much planned but it was still a rude shock… It changed our whole way of life. I expected changes but not to that extent. People joke about the four-hourly nappy changes, the sickness, but unless you experience it firsthand you cannot imagine what it will be like (M4).

I had no real expectations. I did not plan what I would or not do. I went into it open- minded. It was actually more fun than I expected…The only big mistake, the biggest problem with the care I received is that none of the midwives prepared me for how hard breastfeeding was going to be… I wish I had been prepared for that (M6).

The findings from Study 2 pointed to a sense of disconnection and overlap between maternity and CFH services, hospital and community staff, private and public health care. Unfortunately, this indicates that continuity of care is still problematic, despite significant efforts made by Australian governments to address this in the past 15 years (Commonwealth of Australia, 2008, 2011; NSW Health, 2003, 2010b) . Chronic fragmentation between maternity and CFH services is highlighted in recent literature as an obstacle to professionals’ ability to meet the needs of families (Psaila, Kruske, Fowler, Homer, & Schmied, 2014; Psaila, Schmied, Fowler, & Kruske, 2014a; Schmied et al., 2015). The midwifery Continuity of Carer model (Commonwealth, 2011) was introduced in NSW in order to reduce fragmentation of care through pregnancy, birth and the postnatal period (NSW Health, 2010b). In contrast with the Standard Maternity Care model, in which women are seen by whichever midwife is on duty that day, the Continuity of Carer model promotes the development of relationships with a limited number of midwives throughout the woman’s journey through pregnancy and birth (Sandall, Gates, Shennan, & Devane, 2015; S. Tracy et al., 2013). It encourages a strong interface between hospital and community and involves collaboration with various relevant health professionals. The woman receives postnatal care in hospital and is home-visited by a community midwife. This program is found to be particularly effective for women with complex needs (T. Tracy et al., 2013). One important recommendation of the midwifery Continuity of Carer model is that “all women accessing midwifery continuity of carer programs receive midwifery postnatal care at home for at least two weeks after the baby is born” (NSW Health, 2010b, p. 11).

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The NSW Supporting Families Early policy on maternal and child health primary health care (NSW Health, 2010a) promotes a parallel, coordinated and integrated approach to the care of women and their families. Postnatal primary health care home visiting by a nurse is one of the key components of the continuum of perinatal care, beginning in pregnancy. According to the policy:

It is mandatory for Area Health Services to provide Universal Home Visiting. This is the offer and the provision of a home visit by a child and family health nurse to families with a new baby within two weeks of the birth of the baby (NSW Health, 2010a, p. 21).

Mothers in Study 2 reported confusion about the handover of their care in the fortnight that followed their discharge from hospital. One woman recalled:

I did stay in hospital for two days then I went home… I had different nurses visiting me. I came home on the Tuesday and they were not going to come until Sunday but because I had so many problems with my breastfeeding they extended it for a couple of days. They were midwives. Then I got a nurse from the health centre, she came out for the initial visit and then told me when my mother’s group would be (M10).

Conflicting policy recommendations for community postnatal care are likely to have contributed to this problem. The Midwifery Continuity of Carer Model recommends home follow-up by midwives during the two weeks following hospital discharge and the Maternal and Child Health Care Policy directs CFH nurses to complete the universal home visit during the same period of time. There appear to be no clear guidelines about the potential overlapping of service delivery. Recent Australian studies identified the main causes of problems with the transition of care as ineffectual and inconsistent transfer of information, staff shortages, limited communication between professionals and services and tensions around role boundaries (Psaila, Schmied, et al., 2014a, 2014b).

At this point it is worth remembering that the participating mothers in Study 2 identified themselves as having a complex set of needs in the perinatal period. Those who paid for private maternity care claimed that they had not accessed CFH nor been approached to access the service. Considering that 29% of all mothers in Australia give birth in private hospitals in 2012 (Moore, MacDonald, &

Sanjeevan, 2013), a significant number of families potentially miss out entirely on the support of CFH services, including access to more intensive interventions when complex needs are present.

One unexpected observation was the mothers’ interpretation of the chain of events that shaped their postnatal experience and brought them acute emotional distress and frustration. Several mothers were angry and disappointed with the care they received. They did not, however, direct their criticism at the nurses’ poor performance. Instead, they suggested that external factors at organisational and service level might have impacted negatively on the nurses’ individual practice:

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I can imagine that the CFH nurse would not have had time to support me…I understand there is limited funding to help families and I know we were not one of the worst, but still it is sad…I get the feeling that they were doing the best that they could under the circumstances that they work under (M9). I think that the system is such that it is hard. They were people who wanted to help but it is hard with that system (M10).

The constraints which the structure of CFH services can impose on nurses’ roles and clinical practice is well documented in the Australian literature (Kruske et al., 2006). The mothers’ stories support these reports, suggesting that inflexibility in service delivery may have impacted on the nurses’ ability to develop ongoing relationships with families.