A review of evidence around postnatal care and breastfeeding

REVIEW

A review of evidence aroundpostnatal care andbreastfeedingDenis Walsh

AbstractPostnatal care and support for breastfeeding has been central to the

United Kingdom maternity care provision for over 100 years. Over that

time the burden of care has shifted from home to hospital and back to

home again. In the last 10 years, an evidence base has been distilled

around the key components of optimum postnatal care and breastfeeding

support but the implementation of these has been hampered by an

ongoing tensions between a biomedical and social model and by changes

in the organization of community postnatal care. These issues are dis-

cussed in this paper which concludes with some new developments in

care provision.

Keywords biomedical model; midwives; postnatal care; social model

Introduction

Like all areas of childbirth care, postnatal care and breastfeeding

support has changed dramatically over the past 20 years, espe-

cially in the western world. In this paper, these changes will be

detailed and appraised.

The United Kingdom (UK) is unusual among western coun-

tries in having a universal model of home visiting following

birth, undertaken by community midwives. This model has been

in place since the early 1900s and coincided with midwifery

regulation and high rates of homebirth. In the 1970s, when birth

moved into maternity hospitals following the recommendations

of the Peel Report, community midwifery services changed to

largely providing an antenatal/postnatal service. The demand for

postnatal home services has increased as in-patient stays

following hospital birth decreased, particularly since the 1990s.

This change shifted the burden of breastfeeding support to the

community as women choosing to breastfeed have barely

established feeding by discharge from hospital.

As already mentioned, the model of an infrastructure of

primary care based maternity care professionals, offering ante-

natal and postnatal care is not common in other western coun-

tries, where, in the main, women self care initially up to 2 weeks

postnatal following discharge from hospital before accessing

healthcare workers focussed on child health and development. In

the past 10 years, some services in Australia, Ireland, Canada and

the USA have begun adopting a similar model, calling them

Denis Walsh RM MA PhD is Associate Professor in Midwifery at the

University of Nottingham, Queen’s Medical Centre, Nottingham, UK.

Conflicts of interest: none declared.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 21:12 346

postnatal outreach programmes. The notable exceptions to this

are The Netherlands and New Zealand. The former adopted

a national provision of independent group practices of primary

care midwives servicing an extensive homebirth provision

(around 30% nationally) which continues to this day. Following

innovative legislation in New Zealand in the mid 1990s, a similar

model was established there with midwives being paid per

mother booked.

Defining the puerperium

The traditional definition of the puerperium is the time from

immediately after the end of the labour until the reproductive

organs have returned as nearly as possible to their pre-gravid

condition, a period estimated to be around 6e8 weeks, though

there is debate over this. (Recent research suggests that adaption

to motherhood and recovery from childbirth can take much

longer.)

The Nursing & Midwifery Council for the UK define the

postnatal period as ‘the period after the end of labour during

which the attendance of a midwife upon a woman and her baby

is required, being not less than 10 days and for such longer

period as the midwife considers necessary’.

Underpinning models of childbirth provision

Changes in childbirth practices around antenatal and labour care

are reflected to some extent in postnatal care. One of the most

significant and most widely written about has been the medical-

ization of childbirth that has contributed to increasing rates of

caesarean section, induction of labour and epidural use. Advo-

cates for normal birth have blamed the hospitalization of birth for

also ‘pathologizing’ it, lead by increasing obstetric involvement in

antenatal and intrapartum care. Obstetrics would point to

concerns over neonatal and maternal mortality as drivers for

intervention. The truth probably can be found somewhere

between these two views. Nevertheless there remains tension over

the primary model that should be driving provision and these can

be conceptualized as a social or a biomedical model of care.

Below (Table 1) is how sociologists and midwives have con-

trasted the differences between the two models:

The aspects of these models that apply to postnatal care

include the tensions between holistic and patient-led needs

assessment and the expert compartmentalizing assessment into

physiological systems e.g. genito-urinary, gastrointestinal,

cardiovascular. There could also be tension between affirming

physiological processes of adaption to motherhood and early

recognition of pathology. To some extent this tension is also

reflected in differences between trust and fear in the professional

attitude to the phases of birth.

Specifically in relation to postnatal care, Walsh and Newburn

suggest differences between the two models (see Table 2):

Their critique was aimed at ritualized and routine in-patient

hospital care that was premised around a ‘top-to-toe’ physical

checks of mother and baby daily, though expected to be done by

the daytime ward shift and a similar regime after discharge home

undertaken by community midwives on their round of visits.

This model prioritized physical assessment and advice giving by

an expert. By way of contrast they suggested that a social model

would approach care more holistically, responding to the

� 2011 Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.ogrm.2011.09.011

Social model Biomedical model

C Whole person e physiology,

psychosocial, spiritual

Reductionism e powers,

passages, passenger

C Respect and empower Control and manage

C Relational/subjective Expertize/objective

C Environment central Environment peripheral

C Anticipate normality Anticipate pathology

C Art Science

C Local/community Centralized institution

C Technology as servant Technology as partner

C Celebrate difference Homogenization

C Trust Risk

C Intuition/meaning-making Guidelines/objective facts

C Connection Separation

C Feminine (matrescence) Masculine (paternalism)

C Self actualization Safety

Table 1

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mothers expressed needs and mediating care through a relation-

ship of mutual respect and compassion.

Organization of postnatal care

Whether postnatal care is premised on a social or biomedical

model is reflected in how midwives organize themselves to

undertake this care. Traditionally, hospital and community

midwives worked in their respective environments to provide

postnatal care and rarely crossed each other boundaries. Argu-

ably this fragments the experience for women who have

repeatedly complained about inconsistent advice regarding baby

care and breastfeeding with these differences noted between

hospital and home. Hospital postnatal care was quite ritualized

and postnatal wards were run rather like military establishments

with professional hierarchies, division of tasks and time-

regulated routines. Community midwives had more flexibility

and autonomy in how they carried out their care, though patterns

of care were still systematized according to standard note-

keeping proformas.

Since the early 1990s and in response to the publication of

Changing Childbirth, continuity models were piloted in many

centres across the UK. Though these all attempted to address

continuity of care, they differed significantly in how they were

organized. Caseload midwifery has been one of the most

enduring and most heavily researched. This model is based on an

Biomedical model Social model

C Physical care Emotional care

C Checking Supporting

C Specialized skills Enabling innate skills

C Task-orientated focus Focussing on parenting

C Circumscribed duration

of contact

Ongoing/tailing off contact/

linking to a social network

Table 2


individual midwife or a small group practice of up to four

midwives having a discrete caseload of women, usually booked

from the geographical area she/they cover(s). The caseload

midwife or group practice undertakes all the care of women who

at low obstetric risk or share(s) care with an obstetric team if

women have complications. In other words, a key component of

this model is intrapartum continuity, requiring community

midwives to go on-call. This model has been evaluated

very positively, both in terms of clinical outcomes and user

satisfaction.

Another variant of continuity is where community midwives

rotate into midwifery units for intrapartum shifts. This does not

deliver as tighter model of continuity because they may not be

caring for their own women.

Both these models aim to reduce the number of different

carers a woman has in all phases of her care. For postnatal care,

this would ideally be one or two as the number of visits a woman

gets postnatally has traditionally been about four.

Studies performed in the early 1990’s by sociologists uncov-

ered the continuing health inequalities and struggles for women

in poorer socioeconomic groups. Other studies also demon-

strated the continuing discrimination against childbearing

women who were labelled as ‘neurotic’ and diagnosed as having

‘depression’ when this was almost certainly the result of the

major adaptations required of women without an infrastructure

of support that earlier generations had access to. Research per-

formed in the 1990s indicated that a psychiatric approach to

unhappiness and distress in the postnatal period may increase

the iatrogenesis already seen in the medicalization of child-

bearing; this provided a rationale for extended postnatal visiting

and care. However, since 2000, the number of visits and the time

spent visiting at home has actually decreased.

Content of care

The constituents of the postnatal check have varied little over the

decades. The National Institute for Clinical Excellence (NICE)

Guidelines issued in 2006 state that the following routine care

should be offered by the midwife.

� Within the first 24 h after birth, the blood pressure (BP)

should be checked once within 6 h of the first immediate

post-birth BP. Urine should be voided within 6 h and all

women should be encouraged to mobilize.

� Between 2 and 7 days, women should be offered infor-

mation and reassurance about perineal pain and perineal

hygiene, urinary incontinence and micturition, bowel

function, fatigue, headache, back pain, normal patterns of

emotional changes and contraception. There should also

be an enquiry into the woman’s general health.

� From 2 to 8 weeks, resumption of sexual activity should be

discussed as well as advice given if any concerns are raised

about issues in bullet point 2. Finally a health profession

should review the woman’s physical, emotional and social

well-being at 6e8 weeks.

In practice, midwives tend to be more prescriptive than this

and a typical postnatal check in hospital could include the

following:

� palpation of the abdomen to ascertain involution of the

uterus



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� enquiry into vaginal loss and characteristics of lochia

� examination of the perineum if there has been trauma

� enquiry into elimination patterns (micturition and

defaecation)

� encouraging mobility so as to lower the risk of deep vein

thrombosis

� enquiry about the breasts related to engorgement and/or

feeding issues.

Each aspect of this more hand-on approach has been ques-

tioned. Bick and colleagues’ text on postnatal care is still the

definitive text for an evidence-bases approach to the clinical

components of postnatal care. They challenged the notion that

uterine involution is linear and predicable in each women,

noting significant differences in the shrinking of the uterus and

in the characteristics of lochia. They concur with NICE guide-

lines on postnatal care, i.e. that involution should only be

palpated if there is a concern about endometritis and abnormal

blood loss. A problem-based approach can also be applied to

other aspects of postnatal care, including perineal pain. They

suggest establishing a baseline observation of the perineum to

assess bruising, extent of trauma and healing but from then on

only to examine if the woman expresses concern. Post-birth

voiding has been scrutinized by uro-gynaecologists in recent

years, with some hospitals introducing specific measures to

ensure the bladder is emptied completely. These include accu-

rate measurement of post-birth voids within 6 h of the birth and

catheterization if voiding is not achieved. However, this inter-

vention will only be required occasionally. Regarding bowel

elimination, the problem-based approach centres on advice and

treatment for constipation, painful/bleeding haemorrhoids,

faecal urgency/incontinence and anal sphincter injuries. General

principles here are to encourage adequate fluids, a high fibre diet

and optimum pain management.

Bick and colleagues due remind us of the common and under-

recognized complaints of tiredness, headache and backache

following childbirth with a number of practical suggestions to

address these. I would refer readers to their helpful evidence-

based leaflets included in the 2nd edition of Postnatal Care:

Evidence and Guidelines for Management. Their leaflets cover

depression and other psychological morbidity, caesarean section

wound care and breastfeeding. They make a helpful distinction

between postnatal blues, postnatal depression and puerperal

psychosis with increasing severity of clinical features and

increasing need to respond rapidly to them as they escalate.

Arguable, as Caesarean rates climb, there needs to be increasing

awareness and vigilance with regard to wound complications

(infection is the principal one).

Breastfeeding

The evidence on the benefits of breastfeeding is beyond argu-

ment. Year upon year, new evidence supports its benefit, with

the latest being breastfeeding’s link to reduced behavioural

problems in children. It has already been established that

breastfeeding protects babies against gastrointestinal, urinary,

respiratory and middle ear infection and, if there is a family

history, atopic disease as well as juvenile-onset insulin-depen-

dent diabetes. In addition, breast fed babies are less prone

to obesity. The maternal benefits include reduced risk of


premenopausal breast cancer and some forms of ovarian cancer.

Despite this evidence, breastfeeding in the UK is relatively low

compared with other developed world countries. Initiation rates

are between 70 and 80% but fall away markedly in the early

postnatal weeks.

The most common reasons given for stopping breastfeeding

include:

� the baby not sucking or rejecting the breast

� an insufficient milk supply

� suffering with painful breasts or nipples

� that breastfeeding took too long or was too tiring.

Both national policy initiatives and national guidelines have,

in recent years, prioritized breastfeeding, seen most visibly

through the Baby Friendly Initiative (BFI). This initiative came

from the WHO and UNICEF and was launched in 1992. Mater-

nity hospitals achieve accreditation by meeting 10 standards.

These are:

1. Have a written breastfeeding policy that is routinely

communicated to all healthcare staff

2. Train all healthcare staff in the skills necessary to implement

the breastfeeding policy

3. Inform all pregnant women about the benefits and

management of breastfeeding

4. Help mothers initiate breastfeeding soon after birth

5. Show mothers how to breastfeed and how to maintain

lactation even if they are separated from their babies

6. Give newborn infants no food or drink, other than breast

milk, unless medically indicated.

7. Practice rooming-in, allowing mothers and infants to remain

together 24 h per day

8. Encourage breastfeeding on demand

9. Give no artificial teats or dummies to breastfeeding babies

10. Foster the establishment of breastfeeding support groups

and refer mothers to them on discharge from the hospital or

clinic.

There is some evidence that this program increases breast-

feeding uptake and ongoing rates.

Evidence-based approaches to breastfeeding problems

Bick et al have a helpful leaflet in their book on these issues.

They list painful nipples, engorgement, insufficient milk, thrush/

infective mastitis/breast abscess, blocked milk duct, non-

infective mastitis and inverted or non-protractile nipples in

their list and provide recommendations for all based on best

available research. Sore nipples are caused by poor positioning of

the baby on the breast and should not be treated with topical

preparations. If the areola is engorged, the mother may need to

express milk before a feed. Simple analgesia like paracetamol

may be required and unrestricted feeding will help relieve the

problem. Concerns about insufficient milk are best addressed by

demand feeding, emphasizing the importance of fore milk and

hind milk. There should be no limit on the duration of feeds and

observation made on the positioning and attachment of the baby

to the breast. If there are concerns that the breast tissue is

inflamed and/or infected, referral to a medical practitioner

should be made. Flat or inverted nipples are not a contraindica-

tion for breastfeeding.



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Other additional guidance for breastfeeding includes avoid-

ing supplements. These should only be given if medically

indicated. Skin-to-skin should be encouraged immediately

following birth as this have been shown to increase breast-

feeding rates.

Finally in this section, biological nurture has been suggested

as the best approach to breastfeeding initiation. This draws on

observation data suggesting that semi-reclined maternal posi-

tions draw out what have been referred to as primitive neonatal

reflexes (rooting, sucking, swallowing), thus releasing maternal

instinctual behaviours. Conventional wisdom has it that the

human neonate is a dorsal feeder with pressure needed along the

baby’s back. However, observational research suggests that the

newborn is an abdominal feeder and displays anti-gravity

reflexes which aid latching. Breastfeeding initiation may there-

fore be innate for mother and baby and not learned, thus chal-

lenging the routine skills-teaching currently central to

breastfeeding support. This has led to advice to immediately

place the baby prone on the mother’s abdomen after birth, from

where the baby will latch onto the breast with minimum

coaxing.

New models of community postnatal care

MacArthur’s cluster randomized controlled trial recommended

that the community midwife should be encouraged to undertake

a comprehensive health assessment at 10e12 weeks and that this

should effectively replace the 6-week postnatal check tradition-

ally undertaken by the GP, however, this recommendation was

not taken up by the NICE guideline. The NICE guideline was not

prescriptive about the number of visits women would be offered,

despite MacArthur’s finding that women valued regular contact

with their community midwife. In practice, local services have

begun rationing the number of visits under the slogan of ‘selec-

tive visiting’, based on the premise that healthy women do not

require as much support. Community midwives are encouraged

to assess the need of individual women and then adjust the

number of visits according to need. Anecdotally, many commu-

nity midwives have said that they are being performance

managed on reducing the number of visits to three maximum/

woman. This pressure to reduce the amount of home visiting is

driven by the need to reduce costs.

More controversially, community midwives are now being

required to offer women a choice of whether they want a visit at

home or come to community centre (either health centres or

children’s centres) where effectively a postnatal clinic is being

held by the midwife. This change has been introduced without

any evidence that women would prefer this model. Again,

financial pressures appear to be the motivation; a community

midwife has less travelling time if she sees a number of women

in the same facility than travelling to their individual homes.

Ironically, other western countries have started introducing

home postnatal visiting premised on what they perceive as an

excellent UK model.

Changes in community care since 2006 include the advent of

maternity care support workers to supplement and support the

community midwife’s role. Their role concentrates on breast-

feeding support, practical help around the home, the undertaking

of screening tests and referral on to the midwife if there are


concerns. Their role has been evaluated positively at pilot sites

and is currently being rolled out across the country. However,

there is no evidence that they free up community midwives’

time, for midwives to spend more time with the vulnerable and

‘hard to reach’ groups.

Centering pregnancy is another innovation that is being

piloted in the UK after successful evaluation in the USA and

Australia. Relying more on a social model, centering pregnancy is

based on the principle of community engagement of women,

who meet to mutually support each other in the presence of

a health professional (who can answer queries or initiate health

education sessions). These schemes were initially aimed at the

antenatal period but have followed through into the postnatal

period because women valued them so much. They utilize

another movement in healthcare towards patient empowerment

and self help.

Aligned to centering pregnancy is the burgeoning interest in

preparation for parenthood education. This has been highlighted

by health policy as a priority area, not least because it seriously

engages with fathers and their responsibilities for co-parenting.

Conclusion

Postnatal care in the UK has evolved over the past 20 years and

now differs in both organization and, to a less extent, in content

from the 1980’s. These changes mirror an ongoing tension

between a social and biomedical model. The former looks to

women themselves to prioritize and take steps to meet their own

needs as they define them, with the professionals facilitating this

process for them. Learning from each other and learning in

groups are some of the changed structures that this ireflects.

Nevertheless, a biomedical focus remains, especially in

hospital, despite the dramatic fall in postnatal stays. The

biomedical focus seeks to identify signs of early complications

like infection and to ensure prompt treatment. Like other areas of

childbirth, rare catastrophic outcomes such as puerperal sepsis

leading to maternal death tend to drive this focus.

Breastfeeding promotion is still the cornerstone of public

health policy in the UK. Recent guidance urges exclusive

breastfeeding for 6 months. There are now well established

evidence-based guidelines for breastfeeding advice which

maternity care professionals should be following. A

FURTHER READING

Bick D, MacArthur C, Knowles H, Winter H. Postnatal care: evidence and

guidelines for management. London: Churchill Livingstone, 2009.

Bick D. Contemporary postnatal care in the 21st century. In: Byrom S,

Edwards G, Bick D, eds. Essential midwifery practice: postnatal care.

London: Wiley-Blackwell, 2010.

Broadfoot M, Britten J, Tappin D. The Baby Friendly Hospital Initiative and

breastfeeding rates in Scotland. Arch Dis Child Fetal Neonatal Ed

2005; 90: F114e6.

Johanson R, Newburn M, Macfarlane A. Has medicalisation of childbirth

gone to far? BMJ 2002; 321: 892e5.

MacArthur C, Winter H, Bick D. Effects of redesigned community postnatal

care on women’s health 4 months after birth: a cluster randomised

controlled trial. Lancet 2002; 359: 378e85.



Practice points

C Postnatal care is increasingly situated in the primary care setting

C There is a substantial evidence base for the treatment of

common postnatal problems

C The Baby Friendly Initiative increases breastfeeding awareness,

breastfeeding support and tentatively breastfeeding rates

C There is lack of evidence regarding where postnatal advice

from the maternity services should be hosted

C Postnatal care should embrace a social model of health, rather

than a medical model

C Women should direct the priorities around postnatal care

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MacKenzie H, van Teijlingen E. Risk, theory, social and medical models:

a critical analysis of the concept of risk in maternity care. Midwifery

2010; 26: 488e96.

Marchant S. The history of postnatal care; national and international

perspectives. In: Byrom S, Edwards G, Bick D, eds. Essential

midwifery practice: postnatal care. London: Wiley-Blackwell,

2010.

National Institute for Clinical Excellence. Routine postnatal care for

women and their babies. Clinical Guidelines 37 2006.

Walsh D, Newburn M. Towards a social model of childbirth Part 1. Br J

Midwif 2002; 10: 476e81.

Yelland J. Women’s and midwives’ views of early postnatal care. In:

Byrom S, Edwards G, Bick D, eds. Essential midwifery practice: post-

natal care. London: Wiley-Blackwell, 2010.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 21:12 350 � 2011 Elsevier Ltd. All rights reserved.


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A review of evidence around postnatal care and breastfeeding