Experiences of delivery and early parenthood

The Government has pledged to improve NHS maternity services, offering more parents the right to choose where their baby is born by the end of 2009. However, how many extra healthcare professionals will be employed – or how much the expanded services will cost – remains unclear^1,2.

Currently cutbacks and understaffing crises are commonplace³. Chronic shortages in Scottish midwifery services have resulted in a national home-birth rate of 1% – well below the UK average of 3%. Mothers are encouraged to attend hospital to maximise resources⁴.

The RCM is also concerned that cuts in NHS funded ante-natal classes will negatively affect birth and parenting experiences⁵. `We are in danger of denying an important service to a vast section of the community`, says Melanie Every, of the College. `There should not be any shortcuts to make this event as happy and stress-free as possible`, she adds⁵.

But do we know what first-time parents want and expect, from delivery and post-natal care? In issue 10 of Nurture and Nutrition I discussed how parents seek advice on child-rearing⁶. The present article reports the experiences of first-time mums who recently gave birth in UK NHS units.

A random survey of maternity-care experiences in 4800 women⁷ gives a snapshot of the situation across England (Table 1). The full report (available online⁷) shows how practices have changed since 1995⁸.

Ante-natal care
The number of pregnant women who accessed healthcare during the first trimester increased from 82% in 1995 to 86% in 2004⁷, enabling better access to healthcare and screening.
Although the National Service Framework for Children, Young People and Maternity Services recommends direct access to midwives from the first ante-natal contact, this was only available to 13% of women in 2004⁷. Approximately one quarter of mums chose where ante-natal checks took place and 49% received midwifery care exclusively throughout pregnancy⁷. Most of the mums whom I interviewed were unconcerned about seeing several midwives ante-natally. As Neera explains, `All had their own ideas… they showed me there are different ways of doing things.`


Delivery
The 2004 report showed a drop in interventions in vaginal births, such as assisted deliveries, continuous electric fetal monitoring, episiotomies and doctor attendance⁷.

The first-time mothers who I interviewed all had lengthy labours. Two required emergency caesarean sections, one baby was delivered by ventouse and all the mothers considered their labours to be difficult. Their anxieties and insecurities about childbirth fitted with first-time mothers` reports in a recent national survey<sup>7</sup>: they felt less confident in midwifery care compared with mums who had already had children<sup>7</sup>. Ante-natal classes should clearly explain that first labours are likely to be longer and that new experiences are often more daunting; this might improve women`s preparation for the birth. The mums whom I interviewed felt that fears were not always acknowledged. `Although my last midwife was lovely`, others said, `it`s childbirth, it`s meant to hurt!` and `I don`t think you can handle pain`, says Kerry.

Disadvantaged
The 2004 data revealed striking information about women from black/ethnic minority groups (born in or outside the UK), those from deprived areas and single mothers⁷. Compared with other women, they are are:

• More likely to be late to recognise their pregnancy, see their healthcare professional and book ante-natal care;
• More likely to have longer post-natal hospital stays and be visited at home for longer;
• Less likely to be treated with respect or have appropriate communication during the perinatal periods.

Mita – an Asian mother born in a UK hospital – told me that difficulties following her son`s birth were logistical, rather than cultural. `When my mum had me, she just saw the same healthcare professionals all the time.`

Mita felt well prepared for childbirth, having attended NHS ante-natal classes, but she had no dedicated ante-natal midwife and she became unsettled by the high number of students on the labour ward, although she had initially agreed to their observations and examinations. Staff changes are inevitable with prolonged labour, but the issue of student observers remained constant. `Your dignity goes out of the window,` Mita remarked. Remember that although someone may consent to student involvement on admission, they should be asked to re-consent – without pressure – when shifts change or if labour is lengthy.

Kerry also spoke of upheavals during labour, although she does not belong to an ethnic minority or disadvantaged group. In a 12 hour period on the labour ward, she had four midwives and changed rooms two or three times. Both Mita and Kerry attended hospitals in completely different NHS regions, yet they both felt that bureaucracy on the delivery unit got in the way of a positive birthing experience. Administrative and practical difficulties also emerged in early parenthood, as described opposite.

Establishing a feeding regime
Across the UK`s ethnic and social groups, the benefits of breastfeeding are rightly encouraged; the Baby Friendly Initiative (BFI) is working hard to ensure that mothers get optimum breastfeeding support. But it is difficult for healthcare professionals to improve breastfeeding rates without additional hospital-based and community-based resources. Certainly, the Glasgow breastfeeding programme demonstrates how rates can improve, regardless of a family`s socio-economic or educational status.

Good infant feeding practices start ante-natally. The mums I interviewed were encouraged to breastfeed but did not expect problems. `The attitude was that everyone can breastfeed. There was no mention that it can be painful or difficult,` said Kate. Positive encouragement, but also explaining that breastfeeding can be an acquired skill, are both crucial: if problems set in, mums should not feel the blame rests with them.

Step 4 of `Ten Steps to Successful Breastfeeding` is to `Help mothers initiate breastfeeding soon after birth`⁹. Unfortunately, none of the new mums I interviewed initiated breastfeeding within an hour of birth, largely because of staff shortages. Caroline`s story was typical. `I was not immediately encouraged to breastfeed. Lauren wasn`t interested in latching on… After a couple of days without success, one midwife suggested that I fed her in a special nursing room, but they couldn`t allow unlimited access as there weren`t enough staff.` Lauren was soon being fully bottlefed. `I had assumed I would breastfeed but I wish I`d had more support in hospital,` she continued.

The mums frequently mentioned the limited resources on the delivery and post-natal wards. `The staff were under a lot of pressure, working long hours`, commented Mita. When staff are over-stretched, support is easily overlooked. `When Krishan was born, I forgot that you need immediate skin-to-skin contact and no-one encouraged me to feed,` said Mita. `He was drowsy, it was midnight and I was tired.` Delay in initiating breastfeeding set off a chain reaction of difficulties; within 2 weeks Krishan was on infant formula.

Failing this, know where parents can be directed to find information on-line, such as www.cowandgate.co.uk. Just providing a confidence boost can help. Kerry also had problems establishing breastfeeding. `I was over-producing and Sophie couldn`t feed,` she explains. Kerry decided to stop breastfeeding and give expressed milk, in cups and bottles. `I got really stressed,` she added. Three weeks in, an experienced mum helped her to relax and develop a good feeding technique.

Even when breastfeeding has been established, there is always room for healthcare professional support, as Kate explains: `Once I started feeding Elliot I was scared of stopping. I would have liked more information on how to avoid engorgement, how to express and ultimately how to stop. I`ve been very bad at listening to my own instincts`, she adds. Encouragement and self-empowerment from the healthcare professionals is particularly beneficial.

Bottle preparation
Food Standards Agency (FSA) research indicates that parents and healthcare professionals do not think that they get enough information on bottlefeeding, even when parents state a preference for this method¹⁰. The BFI recognises that those who choose not to breastfeed should learn how to make up bottle-feeds¹¹.

Sterilisation is essential for all infant feeding equipment, but do all parents listen fully during ante-natal demonstrations? As Neera explains, probably not – if they think that breastfeeding will work. `They may have told us about bottle-feeding during the classes but I wasn`t paying attention.`

Many women approach first-time parenthood with a firm desire to breastfeed and don`t even consider formula. Consequently, it`s unsurprising that they switch off during feeding/sterilisation demonstrations. It is important, therefore, to repeat the information post-natally – perhaps during baby-weighing clinics – when parents are more aware of the practicalities of infant care. Failing this, know where parents can be directed to find information on-line, such as www.cowandgate.co.uk.

Predominantly, new parents learn about bottlefeeding from their family, friends, or by reading infant formula packs and other literature. Highstandard information is provided by healthcare professionals, but it is delivered in different formats, which can create inconsistencies and discrepancies in education about feed preparation, storage and use^11,12. Parents may not realise when mistakes are being made11. Surveys also reveal parental difficulties in implementing the revised DoH guidelines on bottle feeding¹³ such as making up feeds individually rather than in bulk, or using freshly boiled, but cooled, water. The FSA has called for the DoH guidance to be improved, and for on-pack information to clearly explain why bottle-feeding advice has changed¹².

Other pointers
The parents I interviewed gave good feedback about ante-natal and post-natal healthcare professional support. One omission concerned mixed feeding, which was not discussed in a positive, practical light. `I`ve been doing it since Elliot was a week old`, says Kate. `He still has one breastfeed a day at 7 months!`

Like other young mums⁶, Kerry finds it easier to approach other people for childcare support rather than a healthcare professional. `I know what Sophie needs`, she commented. Kerry`s doing a good job – four months on, Sophie is a contented, predominantly breastfed, baby. Mita`s clinic does not have a regular health visitor. `I rely on the Bounty books and Birth to 5`, she explains. Health Visitors who cover several sites should emphasize the long-term value of these publications and helpful websites to parents.

Conclusions
Healthcare professionals continue to improve experiences of early parenthood. Fewer vaginal births require intervention and more mums start breastfeeding. But the mums who I interviewed recognised that healthcare professionals face challenges because they have limited resources for maternity support. Advice doesn`t have to be face-to-face, or complicated, though. Being approachable and pointing parents towards other good information points, like DoH publications and reputable websites, is worthwhile. `People don`t take you by your lapels and say how parenthood changes the very essence of your being`, explained Kate. It`s hardly any surprise that simply providing encouragement for under-confident parents is often the healthcare professionals key role.

References

1. Hall C. Home birth promise is premature, warn Tories. Telegraph.co.uk. Available at http://www.telegraph.co.uk/news/main.jhtml?xml+/news/2007/04/04/nbirth04.xml. Accessed April 4th 2007.
2. Home births offered to all pregnant women. Guardian Unlimited. Available at http://www.guardian.co.uk/medicine/story/0,,2049097,00.html Accessed April 4 2007.
3. Maternity cuts `a risk to care`. BBC News. Available at http://news.bbc.co.uk/1/hi/health/6240375.stm. Accessed April 6 2007.
4. R Gray. Labour pains prevent choice of home births http://scotlandonsunday.scotsman.com/index.cfm?id=141432005 Accessed April 4 2007.
5. Powdered infant formula research. Available at http://www.food.gov.uk/science/surveys/infantformula. Accessed April 4 2007.
6. http://www.babyfriendly.org.uk/pdfs/infosheets/introduction_infosheet.pdf Accessed May 1 2007.
7. Bottle feeding: 2005 guide. Department of Health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publications PolicyAndGuidance/DH_4123619 Accessed April 6 2007.