midwife visit day after discharge

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Making the most of your midwife after birth

When will my midwife visit me after my baby's been born?

What tests and checks will my midwife carry out, what will happen at my first midwife appointment after my baby's birth, what information will my midwife give me, when will my midwife discharge me, what sort of questions can i ask my midwife, i'm struggling to cope with being a new parent. should i tell my midwife, feeding your baby, your baby’s health.

• whether your baby's umbilical cord stump has fallen off, and how the area's healing
• the number of wet and soiled nappies your baby’s having each day
• the colour of your baby’s skin, in case of jaundice
• that your baby’s eyes and mouth don't have any signs of infection
• inside your baby’s mouth for signs of tongue-tie , if they are struggling to feed

Your physical health

• signs of an infection, bleeding and vaginal discharge
• leaking wee after giving birth (stress incontinence)
• being unable to wee (urinary retention)
• constipation after birth
• sore nipples

Your mental health

• eating healthily
• staying active
• your lifestyle, including how much alcohol you drink and whether you smoke or take illegal drugs
• your contraceptive options
• resuming your sex life
• your baby’s immunisations
• I'm breastfeeding, but I want my partner to feed our baby too. Can I express ? Try to wait until your baby's about eight weeks old before offering them a bottle. Putting them to the breast is the most effective way to establish breastfeeding. There's plenty of things your partner can do in the early days, such as changing their nappy or doing skin-to-skin .
• Can I give my newborn a bath ? You can, but you don’t need to bath them every day. In the first week or so you may find it easier to wash their face, neck, hands and bottom carefully instead. This is sometimes called topping and tailing.
• My baby keeps crying. What can I do? Crying is your baby's main means of communication. As they can't talk, it's the only way they can let you know that they need something. It could be a feed, a nappy change, or just a cuddle. Watch our video for more on why your baby cries .
• How do I get my baby into a routine ? The simple answer is that you can't yet. Until your baby's about three months old, you'll probably find that no two days and nights are the same.
• My baby hasn’t had a poo today. Is there something wrong? Don’t worry, not all babies poo every day - or even every other day. It doesn’t mean there's anything wrong. Mention it to your midwife or health visitor at your next appointment.
• I have passed a blood clot. What should I do? If the blood clot is bigger than a 50p coin then call your midwife for advice. Keep your pad if you were wearing one at the time. Your midwife will ask you lots of questions and may visit if they feel it's necessary.
• I've had a c-section and I'm worried that my stitches are going to come undone. After a c-section you'll be able to see the continuous stitch that closes the skin. But underneath this, your muscle has also been stitched. So although it may feel strange, rest assured that your tummy won't suddenly open up. If you notice holes appearing along your wound, call your midwife for advice.
• What exactly is the fourth trimester?
• Life hacks for your baby's first three months
• Six ways to beat new-parent stress
• Find out How to create a safe sleep environment for your baby

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Bleeding after birth (lochia)

Parents’ tips: mums’ guide to the fourth trimester

High blood pressure in pregnancy (gestational hypertension)

9 things you need to know about midwife appointments

Francesca Whiting is digital content executive at BabyCentre. She’s responsible for making sure BabyCentre’s health content is accurate, helpful and easy to understand.

Where to go next

Your baby after the birth

Having skin-to-skin contact with your baby straight after the birth can help keep her or him warm and can help with getting breastfeeding started.

First feed, weight gain and nappies

Some babies feed immediately after birth and others take a little longer.

The midwives will help you whether you choose to:

• feed with formula
• combine breast and bottle feeds

It's normal for babies to lose some weight in the first few days after birth. Putting on weight steadily after this is a sign your baby is healthy and feeding well.

Read more about your baby's weight , and your baby's nappies, including healthy poo .

Tests and checks for your baby

A children's doctor (paediatrician), midwife or newborn (neonatal) nurse will check your baby is well and will offer him or her a newborn physical examination within 72 hours of birth.

In the early days, the midwife will check your baby for signs of:

• infection of the umbilical cord or eyes
• thrush in the mouth

On day 5 to 8 after the birth, you'll be offered the blood spot (heel prick) test for your baby.

Before you baby is 5 weeks old you should be offered a newborn hearing screening test .

If your baby is in special care , these tests may be done there. If your baby is at home, the tests may be done at your home by the community midwife team.

Learn how to tell when a baby is seriously ill .

Safe sleeping for your baby

Make sure you know how to put your baby to sleep safely to reduce the risk of sudden infant death syndrome (SIDS) .

2 weeks and beyond

You don't need to bathe your baby every day. You may prefer to wash their face, neck, hands and bottom carefully instead.

Most babies will regain their birthweight in the first 2 weeks. Around this time their care will move from a midwife to a health visitor.

The health visitor will check your baby's growth and development at regular appointments and record this in your baby's personal child health record (PCHR) , also known as their "red book".

You after the birth

The maternity staff caring for you will check you're recovering well after the birth.

They will take your temperature, pulse and blood pressure.

They'll also feel your tummy (abdomen) to make sure your womb is shrinking back to its normal size.

Some women feel tummy pain when their womb shrinks, especially when they're breastfeeding. This is normal.

Seeing a midwife or health visitor

Midwives will agree a plan with you for visits at home or at a children's centre until your baby is around 10 days old. This is to check that you and your baby are well and support you in these first few days.

Bleeding after the birth (postnatal bleeding)

You'll have bleeding (lochia) from your vagina for a few weeks after you give birth.

The bleeding usually stops by the time your baby is 12 weeks old.

Non-urgent advice: Speak to your GP, midwife or health visitor if you've got postnatal bleeding and any of these:

• a high temperature over 38C
• the bleeding smells unusual for you
• tummy pain that gets worse
• the bleeding gets heavier or doesn't get any less
• lumps (clots) in the blood
• pain between the vagina and anus (perineum) that gets worse

It could be a sign of infection.

Make sure you know the signs of a serious heavy bleed after giving birth (postpartum haemorrhage, or PPH). This is rare and needs emergency care.

Immediate action required: Call 999 if you've got postnatal bleeding and:

• the bleeding suddenly gets heavier
• you feel faint, dizzy or have a pounding heart

This could mean you're having a very heavy bleed (postpartum haemorrhage) and need emergency treatment.

Read more about your body after the birth , including when you might need urgent medical attention.

Feeding your baby

When you're breastfeeding in the early days , breastfeed your baby as often as they want. This may be every 2 hours.

Let your baby decide when they've had enough (this is called baby-led feeding).

You can express your breast milk if you're having problems with breastfeeding . Problems can include breast engorgement or mastitis .

Get breastfeeding and bottle feeding advice .

Your baby's crying

Crying is your baby's way of telling you they need comfort and care. It can be hard to know what they need, especially in the early days.

There are ways you can soothe your crying baby .

How you feel

Find out how to cope if you feel stressed after having a baby . There are support services for new parents that may help.

You may feel a bit down, tearful or anxious in the first week after giving birth. This is normal.

If these feelings start later or last for more than 2 weeks after giving birth, it could be a sign of postnatal depression .

Postnatal depression and anxiety are common, and there is treatment. Speak to your midwife, GP or health visitor as soon as possible if you think you might be depressed or anxious.

Sex and contraception

You can have sex as soon as you feel ready after having a baby.

There are no rules about when to have sex after giving birth. Every woman's physical and emotional changes are different.

You can get pregnant from 3 weeks (21 days) after giving birth. This can happen before you have a period, even if you're breastfeeding.

You need to start using contraception from 21 days after the birth every time you have sex if you don't want to get pregnant again.

Talk to your doctor, midwife or contraception (family planning) nurse about contraception after having a baby . They can arrange contraception before you have sex for the first time.

Being active may feel like a challenge when you're tired, but gentle exercise after childbirth can help your body recover and may help you feel more energetic.

You should also do pelvic floor exercises to strengthen the muscles around your bladder, vagina and anus.

Page last reviewed: 8 July 2022 Next review due: 8 July 2025

My NHS care after birth

After you have your baby, your midwifery team will want to make sure you are recovering from the birth, and that your baby is healthy and feeding well.

When thinking about postnatal care, bear in mind that day one is the day after your baby’s date of birth, day two is the day after that and so on.

Postnatal appointments

You will have at least three appointments with a midwife after the birth. Ideally this will be with your named midwife or a familiar member of the team. This is not always possible, because it is important for you to be seen at certain specific points and your midwife may not be working that day. Your named midwife will make sure to see you where it is possible.

A basic postnatal check will be carried out for both you and your baby each time you see a midwife from the birth until you are discharged from maternity care. Most women will be discharged after a week and a half to two weeks. Some women and babies will be supported by midwives a little longer, up to one month after birth.

At each postnatal check, you will be asked questions about yourself and your baby. All the questions are important ways of picking up any problems. Don’t be surprised to be talking about all sorts of body fluids!

First visit after the birth

You will be seen by a midwife face to face at home the day after having your baby, or the first full day that you are home, if you have been cared for in hospital or birth centre for one or more nights. If there are any concerns, a plan will be made to see you or speak to you within the next day or two depending on what is needed.

Click here for the contact numbers to your midwifery team

Extra support if needed in the first days

Additional support with feeding your baby may be provided by a midwife or a maternity support worker. You may be offered a phone call to check in with how things are going. There may be other reasons that additional visits in the first days are recommended. This might be for yourself or your baby.

The hormonal changes women undergo in the first few days are enormous, and it is quite normal to feel low perhaps for several days. This is known as the baby blues . Contact your midwife for extra support if you or your partner are not sure what is normal baby blues and what is a more serious mental health concern.

Day five visit

You will have a visit or appointment on day five. Scheduling for this visit is important to offer you postnatal blood screening for your baby. This newborn blood spot test, also known as the heel prick test, is explained below. Day five is the ideal day for these. Any earlier and the tests are less reliable. If it’s later this provides less time to put the right care in place for babies with certain rare conditions before problems develop. 

On the day five visit, your midwife will ask to weigh your baby (without clothes or nappy). You will already have been asked about your baby’s wees and poos. This is how to make sure your baby is feeding effectively. The weight provides another important check.

It is normal for babies to lose weight for two or three days after the birth, before weight gain starts. When babies are first weighed, they have some extra fluid in their system from being in the womb. Just as mothers will pee more often in the days after the birth to get rid of extra fluid, so will babies.

If your baby has lost more than ten percent of the birth weight on day five, a careful feeding plan or further health checks for your baby will be recommended. There may be other signs that feeding is not going well, for example if your baby has a yellow tinge to their skin or eyes known as jaundice.

NHS.uk information about newborn jaundice (yellow colouring)

How to know your baby is getting enough milk

Discharge from maternity service

Between 10 and 28 days after the birth, you will be discharged from the midwifery team. This may be your third postnatal appointment, or your may have had more. At this point, the midwife will check your baby is well and back to birth weight or will be soon. Your midwife will check that you are well and on track with your recovery from the birth.

Your care passes to the Health Visiting Team , who will support your family and your baby up until your baby is 5 years old. Your GP will also play an important role, carrying out a 6–8-week postnatal check for you and your baby, and being on hand for general health concerns.

Your baby’s cord stump will normally have dropped off by now, allowing you to see your baby’s belly button!

Postnatal health checks

Body Changes after Birth

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• NICE Guidance
• Conditions and diseases
• Fertility, pregnancy and childbirth

Postnatal care

NICE guideline [NG194] Published: 20 April 2021

• Tools and resources
• Information for the public

Recommendations

• Recommendations for research
• Rationale and impact
• Finding more information and committee details
• Update information

1.1 Organisation and delivery of postnatal care

1.2 postnatal care of the woman, 1.3 postnatal care of the baby, 1.4 symptoms and signs of illness in babies.

• 1.5 Planning and supporting babies' feeding

Terms used in this guideline

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care . Parents and carers have the right to be involved in planning and making decisions about their baby's health and care, and to be given information and support to enable them to do this, as set out in the NHS Constitution and summarised in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off‑label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Please note that the Royal College of Obstetricians and Gynaecologists has produced guidance on COVID-19 infection and pregnancy for all midwifery and obstetric services.

This guideline uses the term 'woman' or 'mother' and includes all people who have given birth, even if they may not identify as women or mothers. 'Woman' is generally used but in some instances, 'mother' is used when referring to her in relation to her baby.

This guideline uses the term 'partner' to refer to the woman's chosen supporter. This could be the baby's father, the woman's partner, a family member or friend, or anyone who the woman feels supported by or wishes to involve. The term 'parents' refers to those with the main responsibility for the care of a baby. This will often be the mother and the father, but many other family arrangements exist, including single parents.

Principles of care

1.1.1 When caring for a woman who has recently given birth, listen to her and be responsive to her needs and preferences. Also see the NICE guideline on patient experience in adult NHS services .

1.1.2 Be aware that the 2020 MBRRACE-UK reports on maternal and perinatal mortality showed that women and babies from some minority ethnic backgrounds and those who live in deprived areas have an increased risk of death and may need closer monitoring. The reports showed that:

compared with white women (8 per 100,000), the risk of maternal death during pregnancy and up to 6 weeks after birth is:

4 times higher in black women (34 per 100,000)

3 times higher in mixed ethnicity women (25 per 100,000)

2 times higher in Asian women (15 per 100,000; does not include Chinese women)

the neonatal mortality rate is around 50% higher in black and Asian babies compared with white babies (17 compared with 25 per 10,000)

women living in the most deprived areas are more than 2.5 times more likely to die compared with women living in the least deprived areas (6 compared with 15 per 100,000)

the neonatal mortality rate increases according to the level of deprivation in the area the mother lives in, with almost twice as many babies dying in the most deprived areas compared with the least deprived areas (12 compared with 22 per 10,000).

1.1.3 A woman may be supported by her partner in the postnatal period. Involve them according to the woman's wishes.

1.1.4 When caring for a baby, remember that those with parental responsibility have the right be involved in the baby's care, if they choose.

1.1.5 When giving information about postnatal care, use clear language and tailor the timing, content and delivery of information to the woman's needs and preferences. Information should support shared decision making and be:

provided face-to-face and supplemented by virtual discussions and written formats, for example, digital, printed, braille or Easy Read

offered throughout the woman's care

individualised and sensitive

supportive and respectful

evidence based and consistent

translated by an appropriate interpreter to overcome language barriers. For more guidance on communication, providing information (including different formats and languages) and shared decision making, see the NICE guidelines on patient experience in adult NHS services and shared decision making , and the NHS Accessible Information Standard .

1.1.6 Check that the woman understands the information she has been given, and how it relates to her. Provide regular opportunities for her to ask questions, and set aside enough time to discuss any concerns.

1.1.7 Follow the principles in the NICE guideline on pregnancy and complex social factors for women who may need additional support, for example:

women who misuse substances

recent migrants, asylum seekers or refugees, or women who have difficulty reading or speaking English

young women aged under 20

women who experience domestic abuse.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on principles of care .

Full details of the evidence and the committee's discussion are in evidence review G: provision of information about the postnatal health of women .

Communication between healthcare professionals at transfer of care

1.1.8 Ensure that there is effective and prompt communication between healthcare professionals when women transfer between services, for example, from secondary to primary care, and from midwifery to health visitor care. This should include sharing relevant information about:

the pregnancy, birth, postnatal period and any complications

the plan of ongoing care, including any condition that needs long-term management

problems related to previous pregnancies that may be relevant to current care

previous or current mental health concerns

female genital mutilation (mother or previous child)

who has parental responsibility for the baby, if known

the woman's next of kin

safeguarding issues (also see the NICE guideline on domestic violence and abuse and the NICE guideline on child abuse and neglect )

concerns about the woman's health and care, raised by her, her partner or a healthcare professional

concerns about the baby's health and care, raised by the parents or a healthcare professional

the baby's feeding.

1.1.9 Midwifery services should ensure that:

the transfer of care from midwife to health visitor is clearly communicated between healthcare professionals and

the woman or the parents are informed about the transfer of care from midwife to health visitor.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on communication between healthcare professionals at transfer of care .

Full details of the evidence and the committee's discussion are in evidence review B: information transfer .

Transfer to community care

1.1.10 Before transfer from the maternity unit to community care, or before the midwife leaves after a home birth:

assess the woman's health (see recommendations 1.2.2 and 1.2.3 )

assess the woman's bladder function by measuring the volume of the first void after giving birth

assess the baby's health (including physical inspection and observation)

if the baby has not passed meconium, advise the parents that if the baby does not do so within 24 hours of birth, they should seek advice from a healthcare professional (also see recommendation 1.3.12 )

make sure there is a plan for feeding the baby, which should include observing at least 1  effective feed .

1.1.11 Before transfer from the maternity unit to community care, discuss the timing of transfer to community care with the woman, and ask her about her needs, preferences and support available.

1.1.12 When deciding on the timing of the transfer to community care, take into account the woman's preferences, the factors in recommendations 1.1.10 and 1.1.11 and any concerns, including any safeguarding issues (also see the NICE guideline on domestic violence and abuse ).

1.1.13 Before transfer from the maternity unit to community care, or before the midwife leaves after a home birth, give women information about:

the postnatal period and what to expect

the importance of pelvic floor exercises (see the NICE guideline on pelvic floor dysfunction )

what support is available (statutory and voluntary services)

who to contact if any concerns arise at different stages.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on transfer to community care .

Full details of the evidence and the committee's discussion are in evidence review A: length of postpartum stay .

First midwife visit after transfer of care from the place of birth or after a home birth

1.1.14 Ensure that the first postnatal visit by a midwife takes place within 36 hours after transfer of care from the place of birth or after a home birth. The visit should be face-to-face and usually at the woman's home, depending on her circumstances and preferences.

For a short explanation of why the committee made the recommendation and how it might affect practice, see the rationale and impact section on first midwife visit after transfer of care from the place of birth or after a home birth .

Full details of the evidence and the committee's discussion are in evidence review C: timing of first postnatal contact by midwife .

First health visitor visit

1.1.15 Be aware of the Department of Health and Social Care's Healthy Child Programme . Consider arranging the first postnatal health visitor home visit to take place between 7 and 14 days after transfer of care from midwifery care so that the timing of postnatal contacts is evenly spread out.

1.1.16 If a woman did not receive an antenatal health visitor visit, consider arranging an additional early postnatal health visitor visit.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on first health visitor visit .

Full details of the evidence and the committee's discussion are in evidence review D: timing of first postnatal contact by health visitor .

Assessment and care of the woman

1.2.1 At each postnatal contact, ask the woman about her general health and whether she has any concerns, and assess her general wellbeing. Discuss topics that may be affecting her daily life, and provide information, reassurance and further care as appropriate. Topics to discuss may include:

symptoms and signs of potential postnatal mental health problems and how to seek help

symptoms and signs of potential postnatal physical problems and how to seek help

the importance of pelvic floor exercises, how to do them and when to seek help (see the NICE guideline on pelvic floor dysfunction )

factors such as nutrition and diet, physical activity, smoking, alcohol consumption and recreational drug use (also see the NICE guidelines on maternal and child nutrition , weight management before, during and after pregnancy , tobacco and the UK Chief Medical Officer's physical activity guidelines for women after birth )

contraception (see the Faculty of Sexual & Reproductive Healthcare (FSRH) guideline on contraception after pregnancy )

sexual intercourse

safeguarding concerns, including domestic abuse (see the NICE guideline on domestic violence and abuse and the NICE guideline on child abuse and neglect ).

1.2.2 At each postnatal contact, assess the woman's psychological and emotional wellbeing. Follow the recommendations on recognising mental health problems in pregnancy and the postnatal period and referral in the NICE guideline on antenatal and postnatal mental health . If there are concerns, arrange for further assessment and follow up.

1.2.3 At each postnatal contact by a midwife, assess the woman's physical health, including the following:

for all women:

symptoms and signs of infection

vaginal discharge and bleeding (see the section on postpartum bleeding )

bladder function

bowel function

nipple and breast discomfort and symptoms of inflammation

symptoms and signs of thromboembolism

symptoms and signs of anaemia

symptoms and signs of pre‑eclampsia

for women who have had a vaginal birth:

perineal healing (see the section on perineal health )

for women who have had a caesarean section (also see the NICE guideline on caesarean birth ):

wound healing

symptoms of wound infection.

1.2.4 At the first postnatal midwife contact, inform the woman that the following are symptoms or signs of potentially serious conditions, and she should seek medical advice without delay if any of these occur:

sudden or very heavy vaginal bleeding, or persistent or increased vaginal bleeding, which could indicate retained placental tissue or endometritis

abdominal, pelvic or perineal pain, fever, shivering, or vaginal discharge with an unpleasant smell, which could indicate infection

leg swelling and tenderness, or shortness of breath, which could indicate venous thromboembolism

chest pain, which could indicate venous thromboembolism or cardiac problems

persistent or severe headache, which could indicate hypertension, pre‑eclampsia, postdural-puncture headache, migraine, intracranial pathology or infection

worsening reddening and swelling of breasts persisting for more than 24 hours despite self-management, which could indicate mastitis

symptoms or signs of potentially serious conditions that do not respond to treatment.

1.2.5 At each postnatal contact, give the woman the opportunity to talk about her birth experience, and provide information about relevant support and birth reflection services, if appropriate. See the section on traumatic birth, stillbirth and miscarriage in the NICE guideline on antenatal and postnatal mental health and the NICE guideline on post-traumatic stress disorder .

1.2.6 All healthcare professionals should ensure appropriate referral if there are concerns about the woman's health.

1.2.7 At 6 to 8 weeks after the birth, a GP should:

carry out an assessment including the points in recommendations 1.2.1 to 1.2.5 and taking into account the time since the birth

respond to any concerns, which may include referral to specialist services in either secondary care or other healthcare services such as physiotherapy.

1.2.8 For guidance on care for women with symptoms or signs of sepsis, see the NICE guideline on sepsis . If the woman has confirmed or suspected puerperal sepsis, assess the baby for symptoms or signs of infection.

1.2.9 For postnatal care of women who have had hypertension or pre‑eclampsia in pregnancy, see the NICE guideline on hypertension in pregnancy , in particular:

postnatal investigation, monitoring and treatment:

for women with chronic hypertension

for women with gestational hypertension

for women with pre-eclampsia

antihypertensive treatment during the postnatal period, including when breastfeeding

advice and follow-up at transfer to community care .

1.2.10 For postnatal care of women with pre-existing diabetes or who had gestational diabetes, see the recommendations on postnatal care in the NICE guideline on diabetes in pregnancy .

1.2.11 For guidance on assessing the risk and preventing venous thromboembolism in women who have given birth, see the NICE guideline on venous thromboembolism and the Royal College of Obstetricians and Gynaecologists' guideline on reducing the risk of venous thromboembolism during pregnancy and the puerperium .

1.2.12 For guidance on assessing and managing urinary incontinence and pelvic organ prolapse in women who have given birth, see:

the NICE guideline on urinary incontinence and pelvic organ prolapse in women

the NICE guideline on pelvic floor dysfunction .

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on assessment and care of the woman .

Full details of the evidence and the committee's discussion are in:

evidence review F: content of postnatal care contacts

evidence review H: tools for the clinical review of women

evidence review I: assessment of secondary postpartum haemorrhage

evidence review E: timing of comprehensive assessment .

Postpartum bleeding

1.2.13 Discuss with women what vaginal bleeding to expect after the birth (lochia), and advise women to seek medical advice if:

the vaginal bleeding is sudden or very heavy

the bleeding increases

they pass clots, placental tissue or membranes

they have symptoms of possible infection, such as abdominal, pelvic or perineal pain, fever, shivering, or vaginal bleeding or discharge has an unpleasant smell

they have concerns about vaginal bleeding after the birth.

1.2.14 If a women seeks medical advice about vaginal bleeding after the birth, assess the severity, and be aware of the risk factors for postpartum haemorrhage in the NICE guideline on intrapartum care . Also be aware of the following factors, which may worsen the consequences of secondary postpartum haemorrhage:

weight of less than 50 kg at the first appointment with the midwife during pregnancy (booking appointment).

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on postpartum bleeding .

Full details of the evidence and the committee's discussion are in evidence review I: assessment of secondary postpartum haemorrhage .

Perineal health

1.2.15 At each postnatal contact, as part of assessing perineal wound healing, ask the woman if she has any concerns and ask about:

pain not resolving or worsening

increasing need for pain relief

discharge that has a strong or unpleasant smell

wound breakdown.

1.2.16 Advise the woman about the importance of good perineal hygiene, including daily showering of the perineum, frequent changing of sanitary pads, and hand washing before and after doing this.

1.2.17 Consider using a validated pain scale to monitor perineal pain.

1.2.18 If the woman or the healthcare professional has concerns about perineal healing or if the woman asks for reassurance, offer or arrange an examination of the perineum by a midwife or a doctor.

1.2.19 If needed, discuss available pain relief options, taking into account if the woman is breastfeeding.

1.2.20 If the perineal wound breaks down or there are ongoing healing concerns, refer the woman urgently to specialist maternity services (to be seen the same day in the case of a perineal wound breakdown).

1.2.21 Be aware that perineal pain that persists or gets worse within the first few weeks after the birth may be associated with symptoms of depression, long-term perineal pain, problems with daily functioning and psychosexual difficulties.

1.2.22 Be aware of the following risk factors for persistent postnatal perineal pain:

episiotomy, or labial or perineal tear

assisted vaginal birth

wound infection or breakdown

birth experienced as traumatic.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on perineal health .

Full details of the evidence and the committee's discussion are in evidence review J: perineal pain and evidence review H: tools for the clinical review of women .

Assessment and care of the baby

1.3.1 At each postnatal contact, ask parents if they have any concerns about their baby's general wellbeing, feeding or development. Review the history and assess the baby's health, including physical inspection and observation. If there are any concerns, take appropriate further action.

1.3.2 Be aware that if the baby has not passed meconium within 24 hours of birth, this may indicate a serious disorder and requires medical advice.

1.3.3 Carry out a complete examination of the baby within 72 hours of the birth and at 6 to 8 weeks after the birth (see the Public Health England newborn and infant physical examination [NIPE] screening programme ). This should include checking the baby's:

appearance, including colour, breathing, behaviour, activity and posture

head (including fontanelles), face, nose, mouth (including palate), ears, neck and general symmetry of head and facial features

eyes: opacities, red reflex and colour of sclera

neck and clavicles, limbs, hands, feet and digits; assess proportions and symmetry

heart: position, heart rate, rhythm and sounds, murmurs and femoral pulse volume

lungs: respiratory effort, rate and lung sounds

abdomen: assess shape and palpate to identify any organomegaly; check condition of umbilical cord

genitalia and anus: completeness and patency and undescended testes in boys

spine: inspect and palpate bony structures and check integrity of the skin

skin: colour and texture as well as any birthmarks or rashes

central nervous system: tone, behaviour, movements and posture; check newborn reflexes only if concerned

hips: symmetry of the limbs, Barlow and Ortolani's manoeuvres

cry: assess sound.

1.3.4 At 6 to 8 weeks, assess the baby's social smiling and visual fixing and following.

1.3.5 Measure weight and head circumference of babies in the first week and around 8 weeks, and at other times only if there are concerns. Plot the results on the growth chart.

1.3.6 For advice on identifying and managing jaundice, see the NICE guideline on jaundice in newborn babies under 28 days .

1.3.7 If there are concerns about the baby's growth, see the NICE guideline on faltering growth .

1.3.8 Carry out newborn blood spot screening in line with the NHS newborn blood spot screening programme .

1.3.9 Carry out newborn hearing screening in line with the NHS newborn hearing screening programme .

1.3.10 Give parents information about:

how to bathe their baby and care for their skin

care of the umbilical stump

feeding (see recommendations on planning and supporting babies' feeding )

bonding and emotional attachment (see recommendations on promoting emotional attachment )

how to recognise if the baby is unwell, and how to seek help (see recommendations on symptoms and signs of illness in babies )

established guidance on safer sleeping (including recommendations on bed sharing )

maintaining a smoke-free environment for the baby (see also the NICE guideline on tobacco )

vitamin D supplements for babies in line with the NICE guideline on vitamin D supplement use

immunising the baby in line with Public Health England's routine childhood immunisations schedule .

1.3.11 Consider giving parents information about the Baby Check scoring system and how it may help them to decide whether to seek advice from a healthcare professional if they think their baby might be unwell.

1.3.12 Advise parents to seek advice from a healthcare professional if they think their baby is unwell, and to contact emergency services (call 999) if they think their baby is seriously ill.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on assessment and care of the baby .

Full details of the evidence and the committee's discussion are in evidence review F: content of postnatal care contacts and evidence review L2: scoring systems for illness in babies .

Bed sharing

1.3.13 Discuss with parents safer practices for bed sharing, including:

making sure the baby sleeps on a firm, flat mattress, lying face up (rather than face down or on their side)

not sleeping on a sofa or chair with the baby

not having pillows or duvets near the baby

not having other children or pets in the bed when sharing a bed with a baby.

1.3.14 Strongly advise parents not to share a bed with their baby if their baby was low birth weight or if either parent:

has had 2 or more units of alcohol

has taken medicine that causes drowsiness

has used recreational drugs.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on bed sharing .

Full details of the evidence and the committee's discussion are in evidence review M: benefits and harms of bed sharing and evidence review N: co-sleeping risk factors .

Promoting emotional attachment

1.3.15 Before and after the birth, discuss the importance of bonding and emotional attachment with parents, and the approaches that can help them to bond with their baby.

1.3.16 Encourage parents to value the time they spend with their baby as a way of promoting emotional attachment, including:

face-to-face interaction

skin-to-skin contact

responding appropriately to the baby's cues.

1.3.17 Discuss with parents the potentially challenging aspects of the postnatal period that may affect bonding and emotional attachment, including:

the woman's physical and emotional recovery from birth

experience of a traumatic birth or birth complications

fatigue and sleep deprivation

feeding concerns

demands of parenthood.

1.3.18 Recognise that additional support in bonding and emotional attachment may be needed by some parents who, for example:

have been through the care system

have experienced adverse childhood events

have experienced a traumatic birth

have complex psychosocial needs.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on promoting emotional attachment .

Full details of the evidence and the committee's discussion are in evidence review O: emotional attachment .

1.4.1 Listen carefully to parents' concerns about their baby's health and treat their concerns as an important indicator of possible serious illness in their baby.

1.4.2 Healthcare professionals should consider using the Baby Check scoring system:

to supplement the clinical assessment of babies for possible illness, particularly as part of a remote assessment and

as a communication aid in conversations with parents to help them describe the baby's condition.

1.4.3 Follow the recommendations in the NICE guideline on neonatal infection on:

assessing and managing the risk of early-onset neonatal infection after birth (within 72 hours of the birth)

risk factors for and clinical indicators of possible late-onset neonatal infection (more than 72 hours after the birth).

1.4.4 Be aware that fever may not be present in young babies with a serious infection.

1.4.5 If the baby has a fever, follow the recommendations in the NICE guideline on fever in under 5s .

1.4.6 If there are concerns about the baby's growth, follow the recommendations in the NICE guideline on faltering growth .

1.4.7 Be aware of the possible significance of a change in the baby's behaviour or signs, such as refusing feeds or a change in the level of responsiveness.

1.4.8 Be aware that the presence or absence of individual symptoms or signs may be of limited value in identifying or ruling out serious illness in a young baby.

1.4.9 Recognise the following as 'red flags' for serious illness in young babies:

appearing ill to a healthcare professional

appearing pale, ashen, mottled or blue (cyanosis)

unresponsive or unrousable

having a weak, abnormally high-pitched or continuous cry

abnormal breathing pattern, such as:

grunting respirations

increased respiratory rate (over 60 breaths/minute)

chest indrawing

temperature of 38°C or over or under 36°C

non-blanching rash

bulging fontanelle

neck stiffness

focal neurological signs

diarrhoea associated with dehydration

frequent forceful (projectile) vomiting

bilious vomiting (green or yellow-green vomit). See the following sections in other NICE guidelines for more information:

fever in under 5s: clinical assessment of children with fever

neonatal infection: assessing and managing the risk of early-onset neonatal infection after birth and risk factors for and clinical indicators of possible late-onset neonatal infection

sepsis: identifying people with suspected sepsis

meningitis (bacterial) and meningococcal septicaemia in under 16s: symptoms, signs and initial assessment

gastroesophageal reflux disease (GORD) in children and young people: diagnosing and investigating GORD

diarrhoea and vomiting caused by gastroenteritis in under 5s: assessing dehydration and shock

urinary tract infection in under 16s: diagnosis .

1.4.10 If a baby is thought to be seriously unwell based on a 'red flag' (see recommendation 1.4.9) or on an overall assessment of their condition, arrange an immediate assessment with an appropriate emergency service. If the baby's condition is immediately life-threatening, dial 999.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on symptoms and signs of illness in babies .

Full details of the evidence and the committee's discussion are in evidence review L1: signs and symptoms of serious illness in babies and evidence review L2: scoring systems for illness in babies .

1.5 Planning and supporting babies' feeding

General principles about babies' feeding.

1.5.1 When discussing babies' feeding, follow the recommendations in the section on principles of care , and:

acknowledge the parents' emotional, social, financial and environmental concerns about feeding options

be respectful of parents' choices.

For a short explanation of why the committee made the recommendation and how it might affect practice, see the rationale and impact section on general principles about babies' feeding .

Full details of the evidence and the committee's discussion are in evidence review T: formula feeding information and support .

Giving information about breastfeeding

1.5.2 Before and after the birth, discuss breastfeeding and provide information and breastfeeding support (see the section on supporting women to breastfeed ). Topics to discuss may include (see also recommendation 1.5.12 ):

nutritional benefits for the baby

health benefits for both the baby and the woman

how it can have benefits even if only done for a short time

how it can soothe and comfort the baby.

1.5.3 Give information about how the partner can support the woman to breastfeed, including:

the value of their involvement and support

how they can comfort and bond with the baby.

1.5.4 Inform women that vitamin D supplements are recommended for all breastfeeding women (see the NICE guideline on vitamin D ).

1.5.5 Inform women and their partners that under the Equality Act 2010, women have the right to breastfeed in 'any public space'.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on giving information about breastfeeding .

evidence review P: breastfeeding interventions

evidence review Q: breastfeeding facilitators and barriers

evidence review S: breastfeeding information and support .

Role of the healthcare professional supporting breastfeeding

1.5.6 Healthcare professionals caring for women and babies in the postnatal period should know about:

breast milk production

signs of good attachment at the breast

effective milk transfer

how to encourage and support women with common breastfeeding problems

appropriate resources for safe medicine use and prescribing for breastfeeding women.

1.5.7 Encourage the woman to have early skin-to-skin contact with her baby so that breastfeeding can start when the baby and mother are ready.

1.5.8 Those providing breastfeeding support should:

be respectful of women's personal space, cultural influences, preferences and previous experience of infant feeding

balance the woman's preference for privacy to breastfeed and express milk in hospital with the need to carry out routine observations

obtain consent before offering physical assistance with breastfeeding

recognise the emotional impact of breastfeeding

give women the time, reassurance and encouragement they need to gain confidence in breastfeeding.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on the role of the healthcare professional supporting breastfeeding .

Full details of the evidence and the committee's discussion are in evidence review Q: breastfeeding facilitators and barriers and evidence review S: breastfeeding information and support .

Supporting women to breastfeed

1.5.9 Give breastfeeding care that is tailored to the woman's individual needs and provides:

face-to-face support

written, digital or telephone information to supplement (but not replace) face-to-face support

continuity of carer

information about what to do and who to contact if she needs additional support

information for partners about breastfeeding and how best to support breastfeeding women, taking into account the woman's preferences about the partner's involvement

information about opportunities for peer support.

1.5.10 Make face-to-face breastfeeding support integral to the standard postnatal contacts for women who breastfeed. Continue this until breastfeeding is established and any problems have been addressed.

1.5.11 Be aware that younger women and women from a low income or disadvantaged background may need more support and encouragement to start and continue breastfeeding, and that continuity of carer is particularly important for these women.

1.5.12 Provide information, advice and reassurance about breastfeeding, so women (and their partners ) know what to expect, and when and how to seek help. Topics to discuss include:

how milk is produced, how much is produced in the early stages, and the supply-and-demand nature of breastfeeding

responsive breastfeeding

how often babies typically need to feed and for how long, taking into account individual variation

feeding positions and how to help the baby attach to the breast

signs of effective feeding so the woman knows her baby is getting enough milk (it is not possible to overfeed a breastfed baby; see also recommendation 1.5.14 )

expressing breast milk (by hand or with a breast pump) as part of breastfeeding and how it can be useful; safe storage and preparation of expressed breast milk; and the dangers of 'prop' feeding

normal breast changes during pregnancy and after the birth

pain when breastfeeding and when to seek help

breastfeeding complications (for example, mastitis or breast abscess) and when to seek help

strategies to manage fatigue when breastfeeding

supplementary feeding with formula milk that is sometimes, but not commonly, clinically indicated (also see the NICE guideline on faltering growth )

how breastfeeding can affect the woman's body image and identity

that the information given may change as the baby grows

the possibility of relactation after a gap in breastfeeding

safe medicine use when breastfeeding.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on supporting women to breastfeed .

Assessing breastfeeding

1.5.13 A practitioner with skills and competencies in breastfeeding support should assess breastfeeding to identify and address any concerns.

1.5.14 As part of the breastfeeding assessment:

any concerns the parents have about their baby's feeding

how often and how long the feeds are

rhythmic sucking and audible swallowing

if the baby is content after the feed

if the baby is waking up for feeds

the baby's weight gain or weight loss

the number of wet and dirty nappies

the condition of the woman's breasts and nipples

observe a feed within the first 24 hours after the birth, and at least 1 other feed within the first week.

1.5.15 If there are ongoing concerns, consider:

observing additional feeds

other actions, such as:

adjusting positioning and attachment to the breast

giving expressed milk

referring to additional support such as a lactation consultation or peer support

assessing for tongue‑tie.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on assessing breastfeeding .

Full details of the evidence and the committee's discussion are in evidence review R: tools for predicting breastfeeding difficulties .

Formula feeding

1.5.16 Before and after the birth, discuss formula feeding with parents who are considering or who need to formula feed, taking into account that babies may be partially formula fed alongside breastfeeding or expressed breast milk.

1.5.17 Information about formula feeding should include:

the differences between breast milk and formula milk

that first infant formula is the only formula milk that babies need in the first year of life, unless there are specific medical needs

how to sterilise feeding equipment and prepare formula feeds safely, including a practical demonstration if needed

for women who are trying to establish breastfeeding and considering supplementing with formula feeding, the possible effects on breastfeeding success, and how to maintain adequate milk supply while supplementing.

1.5.18 For parents who formula feed:

have a one-to-one discussion about safe formula feeding

provide face-to-face support

provide written, digital or telephone information to supplement (but not replace) face-to-face support.

1.5.19 Face-to-face formula feeding support should include:

advice about responsive bottle feeding and help to recognise feeding cues

offering to observe a feed

positions for holding a baby for bottle feeding and the dangers of 'prop' feeding

advice about how to pace bottle feeding and how to recognise signs that a baby has had enough milk (because it is possible to overfeed a formula-fed baby), and advice about ways other than feeding that can comfort and soothe the baby

how to bond with the baby when bottle feeding, through skin-to-skin contact, eye contact and the potential benefit of minimising the number of people regularly feeding the baby.

1.5.20 For parents who are thinking about supplementing breastfeeding with formula or changing from breastfeeding to formula feeding, support them to make an informed decision.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on formula feeding .

Lactation suppression

1.5.21 Discuss lactation suppression with women if breastfeeding is not started or is stopped, breastfeeding is contraindicated for the baby or the woman, or in the event of the death of a baby. Follow the recommendations in the section on principles of care . Topics to discuss include:

how the body produces milk, what happens when milk production stops, and how long it takes for milk production to stop

self-help advice, such as:

avoiding stimulating the breast

wearing a supportive bra

using ice packs

over-the-counter pain relief

sparingly expressing milk to ease engorgement

when to seek help

medicines that can be prescribed to suppress lactation

the advantages and disadvantages of the different methods of lactation suppression

the possibility of becoming a breast milk donor (also see the section on screening and selecting donors in the NICE guideline on donor milk banks ).

For a short explanation of why the committee made the recommendation and how it might affect practice, see the rationale and impact section on lactation suppression .

Full details of the evidence and the committee's discussion are in evidence review K: information for lactation suppression .

This section defines terms that have been used in a particular way for this guideline.

Bonding and emotional attachment

Bonding is the positive emotional and psychological connection that the parent develops with the baby.

Emotional attachment refers to the relationship between the baby and parent, driven by innate behaviour and which ensures the baby's proximity to the parent and safety. Its development is a complex and dynamic process dependent on sensitive and emotionally attuned parent interactions supporting healthy infant psychological and social development and a secure attachment. Babies form attachments with a variety of caregivers but the first, and usually most significant of these, will be with the mother and/or father.

Continuity of carer

Better Births , a report by the National Maternity Review, defines continuity of carer as consistency in the midwifery team (between 4 and 8 individuals) that provides care for the woman and her baby throughout pregnancy, labour and the postnatal period. A named midwife coordinates the care and takes responsibility for ensuring the needs of the woman and her baby are met throughout the antenatal, intrapartum and postnatal periods.

For the purpose of this guideline, the definition of continuity of carer in the Better Births report has been adapted to include not just the midwifery team but any healthcare team involved in the care of the woman and her baby, including the health visitor team. It emphasises the importance of effective information transfer between the individuals within the team. Having continuity of carer means that a trusting relationship can be developed between the woman and the healthcare professional(s) who cares for her. For more information, see the NHS Implementing Better Births: continuity of carer .

Effective feed

In general, effective feeding includes the baby showing readiness to feed, rhythmic sucking, calmness during the feed and satisfactory weight gain. For a first feed at the breast or with a bottle, effective feeding is shown by the baby latching to the breast or drawing the teat into mouth when offered and showing some rhythmic sucking.

First infant formula

First infant formula or 'first milk' is the type of formula milk that is suitable for a baby from birth to 12 months.

Low birth weight

A birth weight of less than 2,500 grams regardless of gestational age.

Nominal group technique

This is a structured method that uses the opinions of individuals within a group to reach a consensus. It involves anonymous voting with an opportunity to provide comments. Options with low agreement are eliminated and options with high agreement are retained. Using the comments that individuals provide, options with medium agreement are revised and then considered in a second round. For more information, see supplement 1 on methods .

Parental responsibility

See the government definition of parental responsibility .

Parents are those with the main responsibility for the care of a baby. This will often be the mother and the father, but many other family arrangements exist, including single parents.

Partner refers to the woman's chosen supporter. This could be the baby's father, the woman's partner, a family member or friend, or anyone who the woman feels supported by or wishes to involve.

Prop feeding

When a baby's feeding bottle is propped against a pillow or other support, rather than the baby and the bottle being held when feeding.

Responsive feeding

Responsive feeding means feeding in response to the baby's cues. It recognises that feeds are not just for nutrition, but also for love, comfort and reassurance between the baby and mother (or parent in case of bottle feeding). Responsive breastfeeding also involves a mother responding to her own desire to feed for her comfort or convenience. Responsive bottle feeding involves holding the baby close, pacing the feeds and avoiding forcing the baby to finish the feed by recognising signs that the baby has had enough milk, and to reduce the risk of overfeeding. For more information, see the UNICEF Baby Friendly Initiative (BFI) information sheet on responsive feeding .

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• Parenting, childcare and children's services
• Children's health and welfare
• Children's health
• Supporting public health: children, young people and families
• Public Health England

Care continuity between midwifery and health visiting services: principles for practice

Updated 19 May 2021

Applies to England

© Crown copyright 2021

This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3 or write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: [email protected] .

Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned.

This publication is available at https://www.gov.uk/government/publications/commissioning-of-public-health-services-for-children/care-continuity-between-midwifery-and-health-visiting-services-principles-for-practice

Executive summary

Care continuity between midwifery and health visiting enables safe, high quality, personalised care delivered in a timely manner. This continuity is an integral part of delivering the Healthy Child Programme (2009) and reaching the ambitions set in the National Maternity Review (2016) and NHS Long Term Plan (2019).

This document is designed to act as a tool to support local practice implementation and improvements in the care continuity between midwifery and health visiting services. It was developed based on a literature search of current research, an examination of current UK guidance and policy and interviewing midwives and health visitors working in Local Maternity Systems. The document provides evidence and practice examples to consider when improving quality of care through effective transition of information and collaborative practice between midwifery and health visiting services. This document will be relevant to providers of midwifery and health visiting services (including clinical staff and managers) and service commissioners working within integrated care systems and local authorities.

Care continuity between midwifery and health visiting teams can take different forms and be via joint working, sharing information and postnatal handover. Sharing information about women and their babies care also help provide consistent information for women and their families, and is in line with the Making Every Contact Count agenda.

To implement effective care continuity between midwifery and health visiting services, midwives and health visitors need:

• contact details of local midwifery or health visiting teams
• systems (ideally digital) to share relevant information about women and their babies in a timely manner
• protocols regarding when and how to share information and with whom antenatally and postnatally
• contact between midwifery and health visiting services at all levels of service; strategic and operational
• knowledge of each professional’s role and remit and each other’s informational needs
• opportunities to meet face-to-face, to build relationships and discuss care
• access to shared or aligned records that are accessible by both midwifery and health visiting teams as well as the wider primary health team (that is, Family Nurse Partnership ( FNP ) and GPs).
• the same tools and resources to share with women to ensure consistent information is provided

Through care continuity during the antenatal and postnatal period, a seamless service can be provided to women and their families. Other benefits include:

• provision of joint care for those women who need it
• earlier identification of women requiring targeted support
• improved care and consistent information for women and their families, leading to improved outcomes for women and their babies, an improved experience and increased care satisfaction through personalised care
• increased ability of midwives and health visitors to share relevant information in a timely fashion
• improved service pathways, standard operating procedures and information sharing documents such as notification of pregnancy and discharge forms
• better aligned service commissioning and pathways
• increased importance attributed to sharing of information between midwifery and health visiting services

Figure 1 shows a summary of factors contributing to effective care continuity between midwifery and health visiting services. These include:

• effective working relationships between midwife and health visitor
• consistent health and wellbeing message from midwife and health visitor
• ensure health and wellbeing information is evidence based
• consistent information sharing and record keeping
• effective communication between professionals and women and partner
• appropriate and seamless handover tailored to expectant women and partner
• ensuring services are universal in reach and personalised in response
• primary care and intensive family support
• peer support

Taken together these factors:

• ensure that women and their partners are given the same consistent and evidence-based information throughout their maternity journey
• support women and their partner to understand when and how their health information will be shared
• enable care to be tailored to each family’s individual needs

Figure 1. Factors contributing to effective care continuity between midwifery and health visiting services

Summary of actions for main stakeholders

Midwives, health visitors and their service managers.

Recommendations for implementing effective care continuity between midwifery and health visiting services are to:

• create opportunities for midwives and health visitors to meet and discuss women’s care
• share relevant information about women and their babies throughout pregnancy and postpartum
• share lists of names and contact details of professionals in each service
• provide protected time for frontline staff to develop interprofessional communication and new systems for working
• form interprofessional health teams including health visitors, midwives, GPs and other professionals that meet regularly to discuss vulnerable families
• consider part-time secondments to develop interprofessional teams
• jointly develop templates for communication of women’s changing needs across the care pathway
• provide joint visits and appointments for women, particularly for vulnerable families, if acceptable to the individual woman
• provide joint training for midwives and health visitors on breastfeeding, safeguarding, perinatal mental health and other issues
• support collaborative working in maternity outreach hubs and community hubs

Commissioners of midwifery and health visiting services, local authorities and care commissioning groups

• support infrastructure to enable sharing of information
• develop shared electronic platforms for local care records that are accessible by all healthcare professionals involved in a woman and baby’s care
• implement service level agreements for information sharing
• provide midwifery and health visiting service in the same locations such as maternity outreach hubs or community hubs that are easy for women to access
• consider a dedicated co-ordinator or liaison roles to oversee information sharing, transfer of care, arranging visits and referrals
• engage with the local community, including Maternity Voices Partnership , to co-develop information sharing procedures taking into consideration the needs of minority and vulnerable groups
• commission interprofessional training events to develop understanding of practice areas as well as each other’s roles and responsibilities
• monitor outcomes such as breastfeeding monitor the number of antenatal contacts and new born visits within 10 to 14 days postnatal

Introduction

This document sets out the strategic context and research evidence for delivering effective care continuity by midwifery and health visiting services. Care continuity is understood in this context as planned and sustained delivery of high quality support and includes providing consistent messages, effective handover of care, joint working and good working relationships.

This document can be used as a tool to support local practice implementation and improvements in the care continuity provided by midwifery and health visiting services. It provides evidence and practice examples to consider when improving quality of care through effective transition of information and collaborative practice between midwifery and health visiting services. As such this document will be relevant to providers of midwifery and health visiting services (including clinical staff and managers) and service commissioners working within integrated care systems and local authorities.

The expected outcomes from the implementation of these practice principles are:

• more personalised, safer and effective care for women and their families
• consistent information for women and their families, leading to an improved experience and increased care satisfaction
• increased ability of midwives and health visitors to provide a seamless service
• earlier identification of and response to vulnerabilities which may impact on the health of the woman and her baby
• improved service pathways, standard operating procedures and information sharing documents such as notification of pregnancy and handover forms
• better ability of the commissioners of midwifery and health visiting services to support their workforce with care continuity during the antenatal and postnatal period
• more shared visits when clinically appropriate
• more women receiving an antenatal visit by their health visitor

How this document was developed

The development of this document was led by Justine Rooke and Monica Davison (Public Health England) and Dr Ellinor Olander and Dr Patricia Moran (Centre for Maternal and Child Health Research, City, University of London). The document was systematically developed using 3 strands of evidence; academic research, current UK guidance and policy and the experiences of those working in Local Maternity Systems.

Firstly, a literature search was conducted using Scopus and PubMed to identify UK-based empirical studies published since 2015 on care continuity as provided by midwifery and health visiting services. Relevant journals not included in these databases (such as Journal of Health Visiting) were hand searched. Search terms included midwifery, health visiting, collaboration, joint care and partnership and variations of these. Good quality evidence was ensured by only including peer-reviewed research. To be included studies had to provide information regarding care continuity or on factors influencing this. Women’s views and experiences were also included. To be included research could be randomised controlled trials, surveys, service evaluations and qualitative studies with either women or healthcare professionals. These inclusion criteria were used to ensure focus was on practical suggestions. The included research is based on qualitative evidence.

Secondly, the websites of Institute of Health Visiting, National Institute for Clinical Excellence ( NICE ), NHS England, Royal College of Midwives ( RCM ) and Public Health England ( PHE ) were searched to identify relevant and current guidelines as well as practice examples. The database OpenGrey was also used to identify practice examples. Examples were deemed appropriate if they were in line with current guidelines and provided information on positive outcomes for women. The most recent MBRRACE (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries) reports were also checked for relevant information. Further, an email was sent out to all Local Maternity Systems to ask for practice examples. To be included, a practice example had to focus on one of the factors influencing care continuity such as information sharing, joint working and so on.

Finally, 25 interviews were conducted with staff working within the midwifery and health visiting services in England. Participants were recruited via an email to all Local Maternity Systems and the PHE network, and were interviewed between July to September 2020. Participants worked in 13 different Local Maternity Systems and included 15 participants working as midwives, 9 as health visitors and one participant was a service commissioner. Interviews were transcribed verbatim and analysed thematically. Findings confirmed previous research findings, participants viewed care continuity as important, reported different systems of sharing information and supporting families. Participants also discussed how practice had changed during coronavirus (COVID-19).

A draft of this report has been reviewed by representatives from PHE , RCM , NHS England and service managers and local Maternity System staff. Based on this feedback the document was finalised. This document benefitted from many people giving up their time to share their experiences and providing feedback, and we are very grateful for their time and input.

Main drivers, policy and strategic context

The National Maternity Review (Better Births, 2016) outlines a clear vision for maternity services across England to become safer, more personalised, kinder, professional and more family friendly. Maternity services should also enable women to make decisions about their own care and provide support centred on individual needs and circumstances. The review also recommends staff to be supported to work in high-performing teams and deliver care that is women-centred.

Implementing the vision set out in Better Births will support the Secretary of State’s ambition to halve the number of stillbirths, neonatal and maternal deaths and brain injuries by 2025.

The Maternity Transformation Programme seeks to achieve the vision set out in Better Births by bringing together a wide range of organisations to lead and deliver across 11 work streams. There are a number of initiatives implemented as part of the Maternity Transformation Programme which will aid care continuity between midwifery and health visiting services. The Better Births 4 Years On: A review of progress report (2020) presents data on how over 100 community hubs have opened nationally. Community hubs where midwifery and health visiting services are co-located will help provide care continuity for women and their families. The same document reports that over 10,000 women had been booked on a continuity of carer pathway provided by midwives by March 2019. With improved continuity from a named midwife sharing of information with health visiting services will become easier.

By 2023 to 2024, all women will be able to access their maternity notes and information through their smart phones or other devices. This will help women share their maternity notes with their health visitor.

The NHS Long Term Plan (2019) promises to implement an enhanced and targeted continuity of carer model to help improve outcomes for the most vulnerable mothers and babies. By 2024, 75% of women from ethnic minority communities and a similar percentage of women from the most deprived groups will receive continuity of carer from their midwife throughout pregnancy, labour and the postnatal period. Continuity of carer during pregnancy benefits women, and is implemented to reduce health risk and decrease health inequalities (1) . Continuity of carer has also been found to particularly benefit women with complex social factors and ethnic minority women (2 , 3) . Ethnic minority women have been found to have increased risk of maternal mortality . Compared to pregnant non-ethnic minority women, pregnant ethnic minority women were more likely to be admitted to hospital with confirmed SARS-Co-2 infection (4) .

The NHS Long Term Plan discusses increased support for mental health for women and their partners and for breastfeeding. Perinatal mental health services will be improved to enable more women access evidence-based support. All maternity services should be working towards delivering an accredited, evidence-based infant feeding programme. This provides another great opportunity for midwives and health visitors to work collaboratively to provide consistent breastfeeding messages and support to women.

Midwifery and health visiting services had to change rapidly when the COVID-19 pandemic happened in early 2020. The pandemic also impacted on care continuity and new processes had to be introduced. For example, services now had to share information on whether women or anyone in their family had suspected or confirmed COVID-19 or if they were in a shielding category. When midwives and health visitors were co-located information sharing was more readily and easily available but due to home working as a result of the pandemic, online meetings were introduced in many areas. This way of working could facilitate future collaboration between midwifery and health visiting professionals due to its ease and convenience, including cutting down on travel time.

At the start of lockdown, areas with strong established working relationships were able to work quickly to change support and care for women and their families. In practice example 1, Cambridgeshire and Peterborough Local Maternity and Neonatal System share their experiences.

Practice example 1. Changing practice during COVID-19 (Cambridgeshire and Peterborough Local Maternity and Neonatal System)

As professional relationships were already formed between midwifery and health visiting services, when the COVID-19 outbreak happened we were able to rapidly come together as senior leads to plan collaborative support and care for antenatal and postnatal women in our localities. A joint care pathway was developed and shared with all midwifery and health visiting teams across our services within the first weeks of the COVID-19 outbreak. This has been continually updated to reflect the rapid changes in service that resulted from the pandemic.

In other areas, the pandemic reinforced the need for robust information sharing between services. In practice example 2, a new communication and handover process was implemented during the pandemic.

Practice example 2. Implementing a new communication process during the COVID-19 pandemic (Humber, Coast and Vale Local Maternity System)

A midwifery handover document was created to allow midwifery discharge information and requests for future support to be shared between the midwives and the health visitors. This information sharing has ensured a better communication of needs, transparent discharge information, care continuity for the client and a platform to sense check antenatal and baby loss notification knowledge. In addition, the health visiting services set up a single point of contact by telephone facility to receive any midwifery handovers so any concerns could be easily communicated. The immediate outcome is that health visiting services receive midwifery handover information for every mother and baby which allows the health visitors to attend the new birth visit with up to date knowledge of the baby and family. This allows them to be fully informed about the families care needs and ensures that all services are fully informed about postnatal care. The handover information has also allowed us to identify families who were not known to the health visiting service in the antenatal period and to understand why this was. Through collaborative working across a geographical system we have been able to improve the care given to all parents by improving our channels of communication.

Joint home visiting and discharge or handover planning are especially important for families with complex needs so that assessment and appropriate referrals can be made to maximise support available to women (5) .

Practice example 3 provides an example of joint working between health visitor, midwife and GP that enabled appropriate care planning and support for a new mother experiencing mental health issues.

Practice example 3. Joint working to support women during the COVID-19 pandemic (Norfolk and Waveney Local Maternity System)

During the COVID-19 pandemic, a health visitor making a new birth contact via Attend Anywhere video calling with a Universal service user identified low mood in the mother directly relating to her traumatic birth experience. The mother disclosed that she had not shared her feelings with her community midwife or any other health professional. The health visitor sought her consent to speak to other health agencies – midwifery and GP services – this was given. The health visitor then liaised with the community midwifery team to ensure a referral to the debrief service was offered and that the allocated community midwife for this woman was aware. The community midwife directly contacted the health visitor and together they made a joint plan to provide support via video and midwifery home visiting contacts. Midwifery contacts were extended beyond the usual postnatal period and support was provided for the mother to access her GP. A virtual triangle meeting took place between the midwife, health visitor and GP to share information to support the care plan. Excellent communication and liaison between agencies have provided a robust care plan for this service user and ensured handover of care will be fully informed when it takes place.

Why care continuity is important

Benefits for women and their families.

Care continuity helps midwives and health visitors tailor the best care possible, which will have a positive impact on women’s and their babies care and satisfaction with services.

More and more women begin pregnancy with health risks, such as older age, a high body mass index ( BMI ) or with a long term condition. Further, more babies are born into care than ever before : approximately 1 in 200 in 2018 (6) . This is a sharp increase from 2008 when 1 in 400 babies were taken into care within one week of birth. This number is higher in deprived areas: in Blackpool 1 in 47 babies was born into care. Providing joint care is especially needed and important for these high risk women and is likely to benefit these women the most.

In line with Making Every Contact Count , midwives and health visitors can share information to promote positive changes in health behaviour. Midwives and health visitors sharing information will also ensure women receive consistent messages, which in turn can have positive effects on breastfeeding, maternal mental health and child outcomes. Women identify issues especially important to share as mental health concerns or chronic health conditions (7) . Receiving inconsistent or contradicting information on the other hand cause women unnecessary anxiety (7) . An example of early intervention and positive outcomes resulting from the timely sharing of information between midwifery and health visiting services is the smoking relapse prevention pilot carried out in Sheffield, described in practice example 4.

Midwives and health visitors sharing information will also ensure women do not have to repeat information and their experiences every time they see a new healthcare professional. Women report frustration having to repeat the same information to different healthcare professionals, leading to dissatisfaction with care and not feeling heard (7) .

Practice example 4. Smoking relapse prevention pilot in Sheffield (South Yorkshire and Bassetlaw Local Maternity System)

Sheffield implemented a pilot programme of smoking cessation support which integrated the role of health visitors to encourage post-partum follow-up and relapse prevention. Pregnant women’s smoking status was ascertained at booking with referral of all smokers to the stop smoking service. Training was provided for health visitors in using carbon monoxide monitors and identification of health visitor champions to provide ongoing support to women who quit during pregnancy. Information was shared between the midwifery service and champions on their caseload’s smoking status. This information helped health visitor champions to visit women still smoke free at 30 to 34 weeks and followed up at their birth visit offering ongoing support up to 6 to 8 weeks after birth. Health visitors also referred fathers or partners to the stop smoking service. The integration of health visitors led to 54 women (49%) accepting a referral from the midwifery service for postnatal smoking cessation relapse support with the health visitors. Among these women, 47 new birth visits were completed with 67% of women still smoke free, by 6 to 8 weeks post-partum 34 visits were completed with 25 women still smoke free.

Benefits for midwifery and health visiting services

Effective care continuity between midwifery and health visiting will improve midwifery and health visiting services and help services run more smoothly. For example, midwives sharing information about pregnant women will help health visitors deliver the mandated antenatal contact and New Birth Visit. Effective information sharing and joined-up services are also a priority in the revised Healthy Child Programme commissioning guidance (2021). Sharing of information is likely to extend the many benefits associated with continuity of carer as provided by midwives. Collaborative working will also help developing local services and effectively use resources. This includes streamlining support such as antenatal education or breastfeeding clinics and providing joint training for midwives and health visitors. For example, applying for Baby Friendly Initiative accreditation can be a good opportunity for joint training. This accreditation is based on a set of linked evidence-based standards for maternity, health visiting, neonatal and children’s centres services.

Training can also be delivered by one healthcare professional group to another to support workforce development. In practice example 5, a problem with avoidable Newborn Bloodspot testing repeats was identified within the health visiting service, and training was developed and delivered by midwifery services to help reduce these repeats.

Practice example 5. Workforce training: Newborn Bloodspot Testing ( NBS ; South East London Local Maternity System)

A problem with avoidable NBS repeats amongst health visitors was identified within the health visiting team. Avoidable repeats cause anxiety for parents and delayed identification can lead to delayed treatment of an affected baby. To reduce the number of avoidable repeats, the Lambeth Early Action Partnership Health Team (LEAP) provided a 1-hour midwifery-led NBS training session to 23 local Lambeth and Southwark health visitors and practice nurses. The team also set up a system for local health visitors to work with their local Guy’s and St Thomas’s NHS Foundation Trust and Kings College Hospital community midwifery teams to have their practical skills signed off. The training increased the attendees’ confidence and knowledge of NBS. After the training, the LEAP Health Team’s health visitor worked with the local health visiting screening lead to support ongoing internal training for health visitors. The health visitor avoidable NBS repeats went from 23.5% to 7.5% across both trusts. This suggests an improvement in health visitors’ knowledge and skill in undertaking the NBS.

Benefits for midwives and health visitors

Care continuity between midwifery and health visiting will help midwives and health visitors provide safe and tailored care for women and their families. Through collaboration and sharing information, midwives and health visitors can jointly discuss personalised care plans and support. This is more important than ever due to the pregnancy population increasing in health risk and vulnerability. Sharing of information can also lead to informal learning from other healthcare professionals, sharing of resources and job satisfaction knowing safe high quality care is provided to women and their families.

The need for these practice principles

These practice principles are needed for 3 reasons.

First, the Health visiting and midwifery partnership – pregnancy and early weeks document which promotes care continuity between midwifery and health visiting services through the perinatal pathway was published in 2015. Since then, the Maternity Transformation Programme has been implemented, the NHS Long Term Plan published, and the Healthy Child Programme is currently being revised. It is therefore time to provide recent evidence and examples on how to implement this pathway.

Second, there are inconsistences in care continuity as delivered by midwifery and health visiting services across England. Approximately 35% of health visitors report that collaboration with midwives has decreased . Some Local Maternity Systems have clear care pathways and standard operating procedures for how to deliver care continuity, other areas are still developing their procedures. In this document, we have used examples from areas who deliver care continuity between midwifery and health visiting services to share with those areas still developing their local practice.

Third, as previously mentioned, the needs and circumstances of the pregnant population are changing. For example, more and more women with long-term conditions have successful pregnancies. The proportion of deliveries complicated by diabetes mellitus has increased from 5% to 8% between 2013 to 2014 and 2018 to 2019.

Based on these health needs, the pregnant population of today and tomorrow are likely to need more care continuity throughout the perinatal period than previously. Local Maternity Systems may need to revise their current procedures to accommodate this increase in need. Care continuity may be delivered differently depending on the local context, including population and resources.

Main communication points

It’s important that care continuity between midwifery and health visiting services is provided both during and after pregnancy. There are certain important communication milestones, but this should not exclude information being shared outside of these times.

There are 4 communication points where midwifery and health visiting could share information :

Antenatally

• Booking 8 to 12 weeks
• 16 to 28 weeks
• 32 to 36 weeks

Postnatally

4. Birth visit to 10 to 14 days postnatal

Information sharing should consider women’s circumstances, for example for low risk pregnant women, the information shared could be less and at fewer timepoints compared to a woman who lives with complex needs and where ongoing collaboration may be necessary.

After birth, the health visitor will also share information with the woman’s GP ahead of her 6 to 8 week postnatal check with her GP.

Care continuity during and after pregnancy

The appropriate timing and detail of information shared during pregnancy depends on local systems and resources and women’s needs and circumstances. Information sharing and early intervention planning are vital to support women. For example, for pregnant women living with complex social factors midwives could consider a multi-agency needs assessment or refer to a multi-agency team, including health visiting services. Within the community setting, midwives and health visitors may deliver joint antenatal classes (8) , share information about and refer women to community services.

Important for all women is to receive information antenatally about the health visitor’s role. This is particularly important for first time mothers and women who have immigrated to the UK (8 , 9) to make them aware of the importance of the health visiting antenatal contact. Other important information to provide women during and after pregnancy is provided in the Health visiting and midwifery partnership – pregnancy and early weeks document as well as the High Impact Area documents breastfeeding, parental mental health, smoking, alcohol and healthy weight .

After booking, the midwifery team can notify the health visiting team of the pregnancy. They may also notify the FNP if appropriate. This notification can include assessment of social and health need, including needs of the partner or father, and referrals to other agencies such as mental health or social services (see below for examples of information that can be shared by midwifery services with the health visiting team antenatally). The health visiting team should aim to inform midwifery services of a named health visitor for every woman during this time if possible or at least contact details to the health visiting team.

As the pregnancy progresses, the midwife is to communicate any change in the pregnancy status or changes in risk to the family or child to the named health visitor or health visiting team. The midwifery team should aim to notify the health visitor in a timely manner of identifying any significant changes to maternal or child wellbeing.

Important information

The following is a list of the types of information or issues affecting a mother, parent or parents which can be shared between midwifery and health visiting services ahead of the mandated health visiting contact:

• first-time mother
• parents under 19 years
• child protection or social welfare concerns
• domestic abuse
• safeguarding referral
• drug, alcohol or substance misuse
• anxiety, depression or previous post-natal illness
• previous history of stillbirth, neonatal or cot death or baby in NICU
• smokers living in the home
• late notification of pregnancy
• single parent in need of support
• parent chronic physical or mental ill health or disability
• learning difficulties
• mother needs an interpreter (and which language)
• ambivalence regarding pregnancy, low self-esteem or relationship difficulties
• unemployment or financial difficulties
• multiple births
• housing concern
• maternal BMI , below 19 or above 35
• asylum seekers or refugees
• care leavers or history of being in care

An individualised postnatal care and support plan could be developed with the woman in the later weeks of pregnancy. The care and support plan could include:

• relevant factors from the antenatal, intrapartum and immediate postnatal period
• relevant information on family context
• details of the healthcare professionals involved in her care and that of her baby, including roles and contact details
• plans for the postnatal period including infant feeding and physical and emotional wellbeing

After the birth of the baby, the midwifery services should update the health visiting services on the health of both mother and baby. The midwife can explain the purpose of the parent-held personal child health record and how it will be used by the midwife, health visitor and GP. At discharge from community midwifery care, the midwife could complete appropriate sections of the parent-held personal child health record to facilitate transfer of care to the health visitor. A child and family needs assessment, including partner or father’s needs may also be needed.

The New Baby Review is done by the health visitor and should ideally occur within 14 days after birth. However, in some circumstances, this is not possible. Ahead of this review, health visitors should have received information from midwifery services about the woman and the baby they are visiting.

Vulnerable women

An action plan could be a particular consideration for women and partners or fathers with complex social factors . Where a woman or father or partner is identified as vulnerable (for example, maternal mental health, learning disability, obstetric issues, domestic abuse and so on) they can be asked to co-create an individualised action plan with the midwife and health visitor. It’s recommended that a joint meeting with the family is considered. A joint handover in the woman’s home could be beneficial and enable efficient information sharing and care continuity. As this is associated with additional resource, it should be planned with care and provided only when appropriate.

If women require midwifery input after day 14, the midwife and health visitor should aim to have a verbal handover in addition to a written handover. This could be via an online meeting or phone call.

Antenatal contact by health visitors

From 28 weeks of pregnancy a face-to-face contact is to be made with every pregnant woman by the health visiting service. Many women welcome the opportunity to have contact with their health visitor antenatally (9) . This is a mandated contact and often done in the woman’s home. To facilitate this contact, midwifery services need to provide information about women to the health visiting service. Many midwifery services share information after the 20-week scan when the pregnancy is seen as viable. This reduces the risk of health visitors contacting women who have suffered a miscarriage. After the contact, health visitors can share any relevant information about the woman and her pregnancy with the midwifery services.

Sharing of information with GPs

Sharing of information may also need to be done with the woman’s GP. As of 2020 to 2021, there is a new requirement for GPs to offer a 6 to 8 week postnatal check for new mothers, as an additional appointment to that for the baby. This makes communication between health visitors and GPs of greater significance than ever before. For example, for maternal mental health, a health visitor needs to refer to local service pathways or specialist services and inform the woman’s GP. It is also important to communicate with the GP if women have declined health visiting services (10) .

Using evidence to support care continuity between midwifery and health visiting services

In this section, evidence and practice examples are presented to provide suggestions of how care continuity and collaboration between midwifery and health visiting services can be provided. These consist of:

• communication and information sharing
• understanding each other’s professional roles and responsibilities
• co-location of services

Communication and information sharing

Information can be shared in a number of ways; face-to-face or online meetings, telephone or email contacts, forms and through sharing of health records. Face-to-face meetings are particularly valued by healthcare professionals when supporting families with complex needs (5) . Whatever form the communication takes, it needs to be timely and accurate to facilitate good support for women and their family. Practice example 6 shows how a midwife’s communication with a health visitor at postnatal discharge facilitated prompt action on behalf of the family.

Practice example 6: Postnatal communication (Norfolk and Waveney Local Maternity System)

A midwife discharging a postnatal woman called to inform the allocated health visitor that there was little food in the home and the access to Healthy Start support that had been in place had now ended. There were no other concerns and the family was under a universal care pathway. The health visitor was able to access a food parcel that same day and arrange delivery to the family. She then provided telephone support to the family to re-apply for Healthy Start vouchers to supplement their food budget. Although the midwife and health visitor had not needed to complete joint contacts for this family under Universal care, prompt communication of an identified need meant that health visiting services were able to respond quickly and put support in place for this family. Women report that fragmented communication between midwifery and health visiting services sometimes results in receiving inconsistent information from healthcare professionals (7) . Women also find themselves having to repeat their clinical information and needs to each healthcare professional , which can be irritating and distressing, especially for women with pregnancy- or birth-related trauma. To avoid women having to repeat themselves and to enable consistent information, a tool was developed in Sheffield to share infant feeding plans between parents, midwives and health visitors (see practice example 7).

Practice example 7: Supporting breastfeeding plans: development of a tool to communicate infant feeding plans between parents, midwives and health visitors (South Yorkshire and Bassetlaw Local Maternity System)

The infant feeding leads for both midwifery and health visiting met regularly to explore how practitioners could be supported to engage in timely and effective communication. Extensive consultation took place with main stakeholders including community and postnatal midwifery matrons, postnatal ward and health visiting team leaders, advanced neonatal nurse practitioners, midwives, nursery nurses and mothers and it was agreed that a parent-centred approach would be most appropriate in line with the current personalisation agenda. A booklet was developed where parents document feeding and expressing, read when and how the plan will be reviewed, how they will be supported back to breast feeding and access further information. It also assists health professionals to review feeding progress and to update the plan, in collaboration with the parents. In addition, a new feeding plan sticker is completed by the midwife and placed in the Child Health Record to alert the health visitor to consult the plan. This tool is part of a process to promote seamless care between the midwifery and health visiting services in Sheffield, to support mothers whose baby is on a feeding plan. Previously, communication between the midwife, health visitor and mother lacked consistency regarding ongoing support when a feeding plan was in place.

There can be inconsistencies about how much information is shared (5) . To overcome this, clear liaison forms can help information sharing. For example, Buckinghamshire, Oxfordshire and Berkshire West Local Maternity System has communication guidelines and a liaison form to help information sharing. The form outlines any additional support a woman may need at any time during her care, including physical, emotional, social or educational needs.

In some areas, information is shared via forms sent on email. In other areas, IT systems has been developed for rapid and regular information sharing. Information sharing can be challenging when different services have non-compatible or unaligned systems for women’s care records, rendering information inaccessible to other healthcare professionals. This has been identified as a communication barrier between midwifery and health visiting services, but can also include Family Nurse Partnerships and GP services as well (11) . Practice example 8 outlines the information sharing in Bedfordshire, Luton and Milton Keynes Local Maternity System between midwifery and health visiting services.

Practice example 8: Local information sharing agreement for antenatal data exchange within Bedfordshire (Bedfordshire, Luton and Milton Keynes Local Maternity System)

An information sharing agreement was designed to provide the health visiting service in Bedfordshire with the demographic details of every pregnant woman booked for delivery in the Bedfordshire hospitals. This data is used to facilitate antenatal visits by health visitors. Accurate contact and personal details, and date of expected birth are required by the health visiting service after 24 and prior to 32 weeks of pregnancy. Previously, community midwives provided information direct to health visitors, however this was patchy, often inaccurate, provided on paper and has proven difficult to achieve. As a result, a low number of antenatal women received a visit prior to the birth by health visitors.

A joint working group was identified to include commissioners, the maternity service and the health visiting service. The maternity service investigated ways in which their electronic patient records system could be interrogated to obtain the data required and used a software package that could perform this function. A process was drawn up to include the following:

• what information would be required from patient systems and an information-sharing agreement was developed by the group and approved by Caldicott guardians of all services to ensure information governance requirements were met
• women who do not consent to share their information with health visiting services are not included
• secure transfer of data from midwifery to health visiting services
• information is transferred weekly to a secure email via NHS.net and sent to the single point of access at the health visiting service.
• health visiting administrator then access the woman on SystmOne and check pregnancy is still viable and allocate the antenatal visits to the relevant case holding health visitor for contact by 34 weeks

The service is currently achieving 80% of all antenatal visits each month. Of the 20% who have not been seen the majority are booked to deliver in out of area hospitals who do not operate this system. To date, very few women have refused an antenatal contact with the health visitor. Feedback from women is regularly positive, and shows that the service is appreciated. Before the new process started, midwives were trained in the role of the health visitor, the current offer by health visitors for all pregnant women, how to gain consent from women, how to ensure the maternity system can read that consent has been given, what to do if a woman refuses to share information with the health visiting service, the importance of sharing complex information with the health visiting service and the importance of sharing late or out of area women with the health visiting team locally.

Understanding each other’s professional roles and responsibilities

Providing care continuity may be influenced by how well professionals understand each other’s commissioned service and scope of practice. If midwives and health visitors do not understand each other’s roles, it could lead to uncertainty of the tasks and timeframes the other healthcare professional is responsible for (5) . This in turn may cause women to receive conflicting advice, reduced support or incorrect advice about the support available to them from each profession. To increase uptake of the health visiting antenatal contact, Bedfordshire, Luton and Milton Keynes Local Maternity System held training for midwives regarding the health visiting role and service. This, together with an improved electronic information sharing system, increased antenatal contacts (see practice example 8).

Collaborative working and information sharing is enhanced when midwives and health visitors feel part of a team, and have mutual respect and support for each other’s roles (5) . When a midwife-health visitor team approach is adopted with women, it becomes easier for women to seek support and connect with services, and discuss their concerns. Practice example 9 provides an example of how a collaborative partnership can be developed.

Practice example 9: Developing collaborative partnerships (Cambridgeshire and Peterborough Local Maternity System)

Work undertaken by Cambridgeshire and Peterborough Healthy Child Programme (HCP) in partnership with North West Anglia Foundation Trust and The Rosie Maternity Unit at Cambridgeshire University Hospitals Foundation Trust led to the identification of the need for a clear, robust pathway for sharing information concerning antenatal booking. Initially, meetings were arranged with the midwifery leads or matrons from both acute trusts and the Clinical Lead from HCP. The purpose of these initial meetings was to review current practice and identify where improvements could be made, using a PDSA (Planning, Doing, Studying, Acting) approach. These meetings were held face-to-face. Other key individuals who could support progression of this project were identified. The digital midwives were involved very early in the discussions. Proactive commissioners have been pivotal in supporting the building of relationships and facilitating opportunities for change management. There has also been collaboration with service users.

Improved knowledge of each other’s professional roles and responsibilities can be developed through joint training. Face-to-face workshops can help build rapport and getting to know each other. This can result in an appreciation of each other’s roles, workloads and a greater willingness to work collaboratively , with the potential to improve sharing of information and providing women with consistent messages (12) .

Co-location of services

Community hubs or family hubs within settings such as children’s centres can provide one-stop shops for services in convenient locations (13) . Co-location of services can improve formal and informal communication, making it faster and more efficient to collaborate. Face to face contact can also help to build professional relationships , facilitate understanding of each other’s roles, as well as enable joint service planning and delivery (13) .

To ensure greater collaborative working within a co-located setting, clear pathways and joint policies are needed. Alongside these, facilitative organisational structures and strong managerial support needs to be provided (13) . For example, regular meetings between midwifery and health visiting managers allows for practice to be discussed and audited and any changes disseminated quickly.

A number of resources are needed to implement effective care continuity. Resources include appropriate staffing levels and workloads, adequate time, organisational and managerial support and shared IT systems (5) . For example, managerial support is needed to develop standard operating procedures. Barriers to sharing information that can facilitate care continuity includes different service commissioners and therefore funding structures, IT systems, service boundaries and places of work. For example, receiving information about women who give birth in hospitals that are outside the area of the health visiting service can be difficult due to lack of systems and pathways and different ways of working Digital maturity that’s to say how well a maternity service is currently using digital technology and how well prepared the staff, processes and technology are for adopting new digital transformation initiatives, differs across England.

An example of how enhanced resourcing through managerial support and protected staff time led to improved multi-disciplinary working and care planning can be seen in practice example 10 derived from the Lambeth Early Action Partnership ( LEAP ) Health Team.

Practice example 10: Lambeth Early Action Partnership ( LEAP ) Health Team (South East London Local Maternity System)

An interprofessional health care team was formed to examine how the primary care professionals who provide care for pregnant women and their families could work better together. The team comprised 4 front-line clinicians (a local GP, a health visitor, and 2 midwives from different local trusts), operating in a flat hierarchy. Team members were given protected time for this work, which they carried out on the basis of a one day a week secondment from their front-line work. They were given the autonomy to explore any issues that they identified, with a light-touch management steering approach, and were supported to disseminate and implement the solutions they identified. Together they developed a forensic map of what did and did not work, gathering information through shadowing, meeting stakeholders and service mapping. This led to the development of a wide-range of projects including regular interprofessional meetings to discuss vulnerable families, shared access to local care records held electronically, shared practitioner contact lists, interprofessional training, and improved resources for assessment and referral. Outcomes include improved care planning and multidisciplinary working affecting areas such as safeguarding, medical concerns and family issues.

Measures of success or outcome

High-quality data analysis tools and resources are available for all public health professionals to identify the health (and health needs) of the local population. This contributes to the decision-making process and plans to improve services and reduce inequalities. Commissioners and local services need to demonstrate the impact of their services and this can be achieved by using local measures. Below are examples of outcomes and how they can be measured.

The following indicators can be used to measure benefits for women and families:

• smoking at time of delivery (available via Maternal and child health profiles )
• maternal mental health (available via Maternal and child health profiles )
• baby’s first feed breast milk (available via maternity services dashboard )
• breastfeeding at 6 to 8 weeks (available via Maternal and child health profiles )
• infant mortality (available via Maternal and child health profiles )
• low birth weight of term babies (available via Maternal and child health profiles )
• emergency hospital admissions (available via Maternal and child health profiles )
• care satisfaction (available via Friends and family questionnaire , CQC maternity services survey , maternity voices partnership )

Benefits for services

The following indicators can be used to measure benefits for services:

• number of mothers who received a first face-to-face antenatal contact with a health visitor (available via Health visitor service delivery metrics )
• new birth visits completed within 14 days (available via Health visitor service delivery metrics )

Benefits for staff

The following indicators can be used to measure benefits for staff:

• informal learning (staff survey and appraisal)
• sharing of resources (staff survey and appraisal)
• job satisfaction (staff survey and appraisal)

A range of background factors for each local area and other indicators relating to women, children and young people can be found in the Child and maternal health section on PHE Fingertips and in the annually updated local authority child health profiles, which can be extracted in PDF format from the Fingertips platform.

Associated tools and guidance

Better Births , 2016

Better Births 4 Years On: A review of progress , 2020

Healthy Child Programme: Pregnancy and the first 5 years of life , 2009

National Maternity Transformation Programme

NHS Long-Term Plan , 2019

The Best Start for Life: A Vision for the 1,001 Critical Days , 2021

Aquino MR, Olander EK, Needle JJ, Bryar RM. ‘ Midwives’ and health visitors’ collaborative relationships: A systematic review of qualitative and quantitative studies ’, 2016, International Journal of Nursing Studies 62, 193-206

Aquino MRJV, Olander, EK, Bryar RM. ‘ A focus group study of women’s views and experiences of maternity care as delivered collaboratively by midwives and health visitors in England ’, 2018, BMC Pregnancy Childbirth 18, 505

Olander EK, Aquino MRJ, Chhoa C, Harris E, Lee S, Bryar RM. ‘ Women’s views of continuity of information provided during and after pregnancy: A qualitative interview study ’, 2019, Health and Social Care in the Community 27(5), 1214-1223

Sanders J, Channon S, Gobat N, and others. ‘ Implementation of the Family Nurse Partnership programme in England: experiences of key health professionals explored through trial parallel process evaluation ’, 2019, BMC Nursing 18, 13

Antenatal and postnatal mental health: clinical management and service guidance , NICE , 2020

Health visiting and midwifery partnership – pregnancy and early weeks , 2015

Health Visiting Programme: Pathway to support professional practice and deliver new service offer Maternal mental health pathway 3 , 2012

Making Every Contact Count

Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors , NICE , 2010

Postnatal care up to 8 weeks after birth , NICE , 2015

Examples of practice

Leap health team.

The Lambeth Early Action Partnership ( LEAP ) health team consists of 2 midwives, a health visitor, and a GP, led by a public health specialist. The team works within the South East London Local Maternity System, but was funded by the National Lottery Better Start fund. The team does not see families directly but instead works with local organisations to improve communication pathways between midwives, health visitors, GPs and other services to enhance joined-up working amongst the primary health care team surrounding pregnant women and families with children aged 0 to 3.

The team has set up inter-disciplinary training to share skills and is working with their local area on developing trauma-informed services. The team won the 2018 Royal Society of Medicine and Centre for the Advancement of Professional Education John Horder Award for a multi-disciplinary team. In 2019, they won the Maternity and Midwifery Forum Team Award.

The published case studies and local practice examples can be found in the World Health Organization Collaborating Centre library .

• Case studies
• Local practice examples

1. Sandall J and others. ‘Midwife‐led continuity models versus other models of care for childbearing women’, Cochrane Database of Systematic Reviews, 2016 (4)

2. Homer CS and others. ‘Midwifery continuity of carer in an area of high socio-economic disadvantage in London: a retrospective analysis of Albany Midwifery Practice outcomes using routine data (1997 to 2009)’, Midwifery, 2017, 48: pages 1-10

3. Edge D. ‘“It’s leaflet, leaflet, leaflet, then, see you later.” Black Caribbean women’s perceptions of perinatal mental health care’, British Journal of General Practice, 2011, 61(585): pages 256-262

4. Knight M and others. ‘Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population based cohort study’, British Medical Journal, 2020, 369: page m2107

5. Aquino MRJV and others. ‘Midwives’ and health visitors’ collaborative relationships: A systematic review of qualitative and quantitative studies’, International Journal of Nursing Studies, 2016, 62: pages 193-206

6. Bilson A and PWB Bywaters. ‘Born into care: evidence of a failed state’, Children and Youth Services Review, 2020, pages 105-164

7. Olander EK, and others. ‘Women’s views of continuity of information provided during and after pregnancy: A qualitative interview study’, Health and Social Care in the Community, 2019, 27(5): pages 1,214-1,223

8. Aquino MRJV, EK Olander and RM Bryar. ‘A focus group study of women’s views and experiences of maternity care as delivered collaboratively by midwives and health visitors in England’, BMC Pregnancy and Childbirth, 2018, 18(1): page 505

9. Olander EK and others. ‘Women’s views on contact with a health visitor during pregnancy: an interview study’, Primary Health Care Research and Development, 2019, 20: page e105

10. King-Hicks K and J Jessup. ‘A 0 to 19 report on behalf of South East and North West Children, Young People and Families ADPH Networks’, 2020

11. Sanders J and others. ‘Implementation of the Family Nurse Partnership programme in England: experiences of key health professionals explored through trial parallel process evaluation’, BMC nursing, 2019, 18(1): page 13

12. Olander E and others. ‘A multi-method evaluation of interprofessional education for healthcare professionals caring for women during and after pregnancy’, Journal of Interprofessional Care, 2018, 32(4): pages 509-512

13. Olander EK, MRJ Aquino and R Bryar. ‘Three perspectives on the co-location of maternity services: qualitative interviews with mothers, midwives and health visitors’, Journal of Interprofessional Care, 2020, pages 1-9

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Breastfeeding among parous women offered home-visit by a midwife after early discharge following planned cesarean section: Secondary analysis of a randomized controlled trial

Affiliations.

• 1 Department of Obstetrics and Gynecology, Regional Hospital Godstrup, Herning, Denmark.
• 2 Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark.
• 3 Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
• 4 Department of Obstetrics and Gynecology, Aalborg University Hospital, Aalborg, Denmark.
• 5 Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
• 6 Department of Obstetrics and Gynecology, Regional Hospital Horsens, Horsens, Denmark.
• 7 Department of Health Sciences, Lund University, Lund, Sweden.
• PMID: 38075381
• PMCID: PMC10701761
• DOI: 10.18332/ejm/173089

Introduction: Early discharge holds several advantages and seems safe after planned cesarean section among low-risk women. However, breastfeeding rates are lower after cesarean section. Thus, concern has been raised that early discharge among these women may affect breastfeeding even further. Therefore, we aimed to assess the effect of early discharge the day after planned cesarean section on breastfeeding, among parous women when a home-visit by a midwife was provided the day after discharge.

Methods: We conducted a secondary analysis of a randomized trial. Parous women (n=143) planned for cesarean section were allocated to either discharge within 28 hours after planned cesarean section followed by a home visit the day after (early discharge) or discharge at least 48 hours after planned cesarean section (standard care). The participants filled in questionnaires approximately 2 weeks before delivery and 1 week, 4 weeks, and 6 months postpartum.

Results: The proportions of women initiating breastfeeding were 84% versus 87% (early discharge vs standard care). After 6 months, 23% versus 21% were exclusively breastfeeding, while 29% versus 42% were partially breastfeeding. The mean duration of exclusive breastfeeding was 3.4 months (SD=2.3) in both groups. None of these differences was statistically significant. In both groups, the women's breastfeeding self-efficacy score before cesarean section correlated with the duration of breastfeeding. After 4 weeks, low-score rates were 28% versus 30%.

Conclusions: Early discharge with follow-up home visits by a midwife after planned cesarean section in parous women is feasible without compromising breastfeeding.

Keywords: breastfeeding; cesarean section; house calls; length of stay; postnatal care; self-efficacy.

© 2023 Kruse A. R. et al.

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Breastfeeding among parous women offered home-visit by a midwife after early discharge following planned cesarean section: Secondary analysis of a randomized controlled trial

Anne r. kruse.

1 Department of Obstetrics and Gynecology, Regional Hospital Godstrup, Herning, Denmark

2 Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark

3 Department of Clinical Medicine, Aarhus University, Aarhus, Denmark

Finn F. Lauszus

Axel forman, ulrik s. kesmodel.

4 Department of Obstetrics and Gynecology, Aalborg University Hospital, Aalborg, Denmark

5 Department of Clinical Medicine, Aalborg University, Aalborg, Denmark

Marie B. Rugaard

6 Department of Obstetrics and Gynecology, Regional Hospital Horsens, Horsens, Denmark

Randi K. Knud-en

Eva-kristina persson.

7 Department of Health Sciences, Lund University, Lund, Sweden

Iben B. Sundtoft

Niels uldbjerg, associated data.

The data supporting this research cannot be made available for privacy or other reasons. Supply of data to other parties was not included in the approval from the Danish Data Protection Agency or the Central Denmark Region Ethics Committee.

INTRODUCTION

Early discharge holds several advantages and seems safe after planned cesarean section among low-risk women. However, breastfeeding rates are lower after cesarean section. Thus, concern has been raised that early discharge among these women may affect breastfeeding even further. Therefore, we aimed to assess the effect of early discharge the day after planned cesarean section on breastfeeding, among parous women when a home-visit by a midwife was provided the day after discharge.

We conducted a secondary analysis of a randomized trial. Parous women (n=143) planned for cesarean section were allocated to either discharge within 28 hours after planned cesarean section followed by a home visit the day after (early discharge) or discharge at least 48 hours after planned cesarean section (standard care). The participants filled in questionnaires approximately 2 weeks before delivery and 1 week, 4 weeks, and 6 months postpartum.

The proportions of women initiating breastfeeding were 84% versus 87% (early discharge vs standard care). After 6 months, 23% versus 21% were exclusively breastfeeding, while 29% versus 42% were partially breastfeeding. The mean duration of exclusive breastfeeding was 3.4 months (SD=2.3) in both groups. None of these differences was statistically significant. In both groups, the women’s breastfeeding self-efficacy score before cesarean section correlated with the duration of breastfeeding. After 4 weeks, low-score rates were 28% versus 30%.

CONCLUSIONS

Early discharge with follow-up home visits by a midwife after planned cesarean section in parous women is feasible without compromising breastfeeding.

Early skin-to-skin contact and rooming-in after delivery are well-known factors in facilitating breastfeeding 1 . Hence, the first hours and days postpartum constitute a crucial period in enabling breastfeeding 1 . Even though WHO recommends exclusive breastfeeding until the child is 6 months old, studies report considerable variation in exclusive breastfeeding rates, e.g. 1–37% at 6 months postpartum 2 - 5 . Besides these differences between populations, the duration of breastfeeding is associated with several individual factors such as maternal education level, previous breastfeeding experiences, maternal breastfeeding self-efficacy score, and delivery mode 6 - 9 . Hence, compared to the situation after vaginal birth, breastfeeding may be even more challenging after a cesarean section (CS) 2 , 9 - 12 . Yet, once breastfeeding is established, the mode of delivery might not have an effect on breastfeeding continuation 8 , 9 . Therefore, the early postpartum period after CS seems to be of major importance.

During the last decades, early discharge after uncomplicated vaginal delivery has become more common 13 . This routine might increase the risk of breastfeeding problems, jaundice and re-admission 14 , 15 . However, it may hold several advantages for the family such as staying at home in a familiar environment, being with the entire family, and supporting the parental empowerment 13 , 16 . Also, after CS early discharge is practiced. Among low-risk women, this procedure is safe and feasible concerning postoperative recovery 17 , 18 . However, it remains unclear whether breastfeeding is affected by this routine. One may fear that the reduced time for inpatient guidance on breastfeeding compromises the initiation of breastfeeding. Published results on the topic are conflicting, i.e. an observational study demonstrated no association, while others report that late discharge had a positive effect on duration of exclusive breastfeeding 19 - 21 . However, the interpretation of these results is challenged by the designs of the studies, which hardly addressed contemporary definitions of early discharge and provided limited information on follow-up after discharge.

Offering postpartum home visits may promote early discharge and, further, support the sense of continuation and need of consistent advice requested by the women 3 , 22 , 23 . These home visits should include breastfeeding counselling, since breastfeeding support from a healthcare professional was found important for breastfeeding success 5 , 24 , 25 . When evaluating breastfeeding support from healthcare professionals, women reported positive factors such as an authentic presence, an empathetic approach, and an encouraging dialogue 26 . These elements might be easier to obtain during a home visit in which the woman feels comfortable and the interruptions are less, compared to during a hospital stay. Further, the provided home care may be more family centered and the partner is more likely to play a central supportive role also regarding breastfeeding in this setting 27 .

Previous randomized controlled trials (RCTs) on early discharge and enhanced recovery programs after CS have addressed breastfeeding as a secondary outcome 14 , 28 - 30 . A study from the United States showed that an enhanced recovery program after CS did not significantly increase the rate of discharge on day 2 (9% vs 3%), instead it increased exclusive breastfeeding at discharge (67% vs 48%) and continued breastfeeding 6 weeks postpartum (71% vs 38%) 29 . A Malaysian RCT found similar rate of exclusive breastfeeding 6 weeks postpartum when discharge was the first post-operative day compared to discharge on day 2 (45% vs 45%) 30 . On the other hand, an Egyptian RCT found that initiation of breastfeeding was negatively affected by discharge within 24 hours compared to discharge after 72 hours (62% vs 68%) 14 . Therefore, it remains unclear how breastfeeding is affected by the length of hospital stay, and especially how postpartum follow-up such as home-visits may alter this effect.

Besides measuring the proportion of women initiating breastfeeding and its duration, breastfeeding self-efficacy is also an outcome of interest. Self-efficacy in general is described by Bandura 31 as a person’s belief in itself being able to exercise control and thereby manage a situation or task. It is determined by internal personal factors, but also by the external environment. The women’s attitude towards breastfeeding can be assessed by the breastfeeding self-efficacy score. Studies have found that breastfeeding self-efficacy score is correlated to duration of breastfeeding 32 .

Even though early discharge seems safe after planned CS among low-risk women 33 , 34 , the studies mentioned above allow no definite conclusions on the effect on breastfeeding. Therefore, we performed a secondary analysis of a Danish RCT on early discharge after planned CS (≤28 vs >48 hours). The secondary outcomes were initiation of breastfeeding, self-efficacy score, and duration of breastfeeding.

This study included parous women planned for term CS at two obstetrical departments in Denmark from September 2016 to September 2019. The method was previously described in detail 18 . The primary outcome of the RCT was parental sense of security compared between two groups allocated for either standard or early discharge. The latter was offered a home visit by a midwife. In this study, we performed a secondary analysis of breastfeeding in this setting.

Inclusion and exclusion criteria

The inclusion criterion was planned CS in a parous woman. Exclusion criteria were multiple pregnancy, pre-pregnancy BMI ≥35 kg/m 2 , age <18 years, inability to read and write Danish, living alone, planned prolonged observation of the woman or the new-born, and previous negative breastfeeding experiences, leading to a planned prolonged hospital stay.

Participants

The participants were recruited from the outpatient clinic when the planned CS was decided. They received written information and oral information by telephone. After informed consent was obtained, the participants were randomly allocated 1:1 to either early discharge or standard care. This allocation took place approximately 2 weeks before the planned CS.

Intervention (early discharge group)

Discharge was intended within 28 hours after CS. These women were offered a home visit by a midwife the day after discharge. The home visit included guidance on breastfeeding in addition to standard examinations of the newborn, weight control, a hearing test, and dried blood spot screening for congenital conditions.

Control (standard care group)

Discharge was intended at least 48 hours after CS. Standard examinations of the newborn, weight control, a hearing test, and dried blood spot screening for congenital conditions were performed before discharge. Women in this group were offered guidance on breastfeeding during hospital stay but were not offered a home visit.

Otherwise, both groups received the same standard perioperative care during hospital stay and fulfilled the same criteria for discharge 18 . Decision on whether the woman was ready for discharge as intended was made between the woman and the personnel. Both groups received the same standard home visits by a local child healthcare nurse about 4 to 5 days after birth.

The outcomes were initiation and duration of breastfeeding and breastfeeding self-efficacy score. Breastfeeding self-efficacy score 31 , 32 was measured using the question: ‘How certain are you that you will breastfeed exclusively until 4 months postpartum?’. The response options were: ‘very certain’, ‘certain’, ‘do not know’, ‘uncertain’, and ‘very uncertain’. This question was answered in a diary approximately 2 weeks before planned birth and at 1 week and 4 weeks postpartum. Uncertain and very uncertain were categorized as low breastfeeding self-efficacy.

Six months postpartum, participants received a questionnaire by e-mail regarding duration of exclusive and partial breastfeeding. Breastfeeding was defined as partial if the child received anything else than mother’s milk, such as formula or any kind of complementary food. Duration was reported in numbers of months, rounded up to the nearest half month.

Statistical analysis

Sample size was based on the primary outcome of the RCT 18 . Data were analyzed using STATA 17 (College Stations, Texas, USA). Analyses were performed according to the intention-to-treat principle. Chi-squared or Fisher’s exact test, as appropriate, were used for categorized outcomes. Breastfeeding self-efficacy and duration of breastfeeding were analyzed using linear regression and survival analysis. A two-sided p<0.05 was chosen as level of significance.

A total of 266 parous women fulfilled the inclusion criteria. Of these, 143 parous women (54%) accepted participation. Thus, 72 were allocated to early discharge (≤28 hours after CS) and 71 to standard care (discharge >48 hours after CS). The women in the two groups did not differ regarding their basic characteristics ( Table 1 ) 18 . Before the CS, 89% in the early discharge group and 90% in the standard care group planned to breastfeed.

Characteristics of the women included in the randomized controlled trial scheduled for planned cesarean section, Denmark, 2016–2019 (N=143)

Of the 143 participants, 75% (54/72) and 73% (52/71), early discharge and standard care, respectively, filled in the diary within the first month after CS. Six months postpartum, 78% (56/72) and 87% (62/71) answered the follow-up questionnaire. Among the responders, 84% versus 87% initiated breastfeeding (early discharge vs standard care, p=0.63, Table 2 ). Six months postpartum, 23% versus 21% were exclusively breastfeeding (p=0.77), while 29% versus 42% were partially breastfeeding (p=0.13). The mean duration of exclusive breastfeeding was 3.4 months (SD=2.3) in both groups (p=0.85). Survival analysis did not reveal any differences in duration of breastfeeding between the groups, neither regarding any breastfeeding (p=0.26, Figure 1 ) nor exclusive breastfeeding (p=0.99, Figure 2 ). A subgroup analysis comparing women discharged ≤28 versus >48 hours after CS, regardless of group allocation, found comparable results (p=0.98 and 0.49, respectively, Supplementary file Figure 1).

Breastfeeding among women in early discharge versus standard care group, answering a questionnaire 6 months after planned cesarean section, in a randomized controlled trial, Denmark, 2016–2019 (N=118)

Any breastfeeding after planned cesarean section among women randomized for early discharge or standard care, Denmark, 2016–2019 (N=118)

Exclusive breastfeeding after planned cesarean section among women randomized for early discharge or standard care, Denmark, 2016–2019 (N=118)

We found a strong association between maternal breastfeeding self-efficacy and duration of breastfeeding (p<0.001, linear regression, Table 3 ) with no significant differences between the groups ( Table 4 ). Low breastfeeding self-efficacy score was reported among 19% versus 24% before and 28% versus 30% at 4 weeks after CS ( Table 4 ).

Breastfeeding self-efficacy before cesarean section and duration of breastfeeding among women answering the questionnaire before and after cesarean section, in a randomized controlled trial, Denmark, 2016–2019 (N=91)

Proportion of women undergoing planned cesarean section with low breastfeeding self-efficacy score a , in a randomized controlled trial, Denmark, 2016–2019

In this study, we randomized parous women undergoing planned CS to either early discharge (≤28 hours after CS) followed by a home visit or standard care (discharge >48 hours after CS) and found no significant differences in breastfeeding initiation, duration, or the rate of women with low breastfeeding self-efficacy score.

Previous studies also found that breastfeeding self-efficacy, as well as breastfeeding in general, is impaired among women after CS 10 , 11 . This may indicate that these women need intensive breastfeeding support under as optimal conditions as possible. In our study population, we found a total of 21% (19% vs 24%, respectively, in the two groups) with low breastfeeding self-efficacy before CS. This is comparable to the 34% found in another Danish study, which in contrast to our study included women regardless of parity and delivery mode 32 . Since the breastfeeding self-efficacy score predicts increased risk of early breastfeeding cessation, this may help us identify women appropriate for increased support either during hospital stay or in their home surroundings.

Three other RCTs 14 , 29 , 30 support our results regarding breastfeeding after early discharge, including post-discharge follow-up after planned CS in parous women. One of these RCTs was conducted in Malaysia, where the University hospital ‘offered comprehensive healthcare to the public at subsidized rates or for free’ 30 . The study included 360 mostly parous women undergoing planned CS allocated to intended discharge on day 1 or day 2. After discharge, the women had free access to the clinic, which was open at all hours, whereas they did not receive home visits. At 6 weeks, the rate of exclusive breastfeeding was 45% in both groups. Another RCT was conducted in Egypt, where the University Clinic in Cairo offered ‘medical service totally free of any charges’ including 2998 mostly parous women allocated to discharge after 24 or 72 hours following planned or acute CS 14 . After discharge the women had access to medical help in an outpatient clinic. The rates of breastfeeding after 6 weeks were 62% and 68%, respectively. Despite these relatively high breastfeeding rates, they found a significant difference between the groups (p=0.001). Yet, one may speculate if postpartum home visits would have levelled out this difference.

A limitation of RCTs on topics like breastfeeding is that they do not account for the birth and the establishment of parenthood as a life transition, which deserves individualized managing 35 . Thus, a meta-synthesis on parental experiences of early postnatal discharge concluded that ‘the mothers’ and fathers’ experiences of responsibility, security and confidence in their parental role, were positively influenced by having the opportunity to be together as a family, receiving postnatal care that included both parents, having influence on time of discharge, and getting individualized and available support focused on developing and recognizing their own experiences of taking care of the baby’ 16 . This emphasizes the importance of individualized and modifiable plans for length of hospital stay as well as for the guidance regarding breastfeeding 3 , 16 , 26 , 36 . Therefore, it is essential that we do not implement early discharge at the expense of shared decision-making 16 .

Even though we did not find a significant difference in breastfeeding rates when comparing women discharged on day 1 and 2, it is important to acknowledge that women often report breastfeeding difficulties on day 3, which increases the risk of cessation. Therefore, optimal organization, extent, and timing of follow-up after discharge constitute important future research topics; not only for women delivered by planned CS but for all women who intend to breastfeed.

Strengths and limitations

The strengths of the study include the randomized design and the high response rate (83%) to the questionnaires. It is a limitation that it is a secondary analysis; thus, the sample size was not based on breastfeeding outcomes (i.e. the results are only hypothesis generating). Further, only 54% of eligible patients accepted participation, which may have induced recruitment bias and, hence, affected the internal validity. Also, the external validity may be compromised by the Danish setting. Danish culture supports a strong tradition for breastfeeding, including focus on skin-to-skin contact supported by the staff within the first hours after birth. Furthermore, the Danish healthcare system already offers a postpartum follow-up provided by a local child healthcare nurse starting within the first week after birth.

Among low-risk parous women undergoing planned CS, early discharge after shared decision-making does not compromise breastfeeding. However, a prerequisite for this conclusion might be the inclusion of home visits by a healthcare professional with expertise in breastfeeding. Regarding the importance of individualized plans for the women, further research is needed.

Supplementary Material

Conflicts of interest.

The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none was reported.

There was no source of funding for this research.

ETHICAL APPROVAL AND INFORMED CONSENT

Ethical approval was obtained from the Danish Data Protection Agency (Approval number: 1-16-02-513-15; Date: 2 October 2015), and the Central Denmark Region Ethics Committee (Approval number: 1-10-72-195-15; Date: 21 October 2015). Participants provided informed consent. Registered at clinicaltrials.gov ( {"type":"clinical-trial","attrs":{"text":"NCT02911727","term_id":"NCT02911727"}} NCT02911727 ).

DATA AVAILABILITY

Provenance and peer review.

Not commissioned; externally peer reviewed.