Health Technology Assessment 2003; Vol 7: number 37
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1 Department of Public Health and Epidemiology, University of Birmingham, UK
2 Thames Valley University, Slough, UK
3 University of Surrey, Guildford, UK
4 School of Health Sciences, University of Birmingham, UK
5 Department of Economics of Education, Columbia University, New York, USA
6 Birmingham Womens Hospital NHS Trust, Birmingham, UK
This study aimed to develop, implement and test the cost-effectiveness of a new model of postnatal care compared with current care on womens physical and psychological health.
This was a cluster randomised controlled trial, with general practice as the unit of randomisation. Recruited women were followed up by postal questionnaire at 4 and 12 months postpartum and further data collected from midwife and general practice sources.
Thirty-six general practice clusters were randomly selected and recruited from all those in the West Midlands Health Region and 17 randomly allocated to intervention and 19 to control. All antenatal women within recruited practices were eligible for inclusion, unless not expected to be resident for postnatal care. Attached midwives recruited 1087 women in the intervention and 977 in the control practice clusters.
The redesigned care focused on the identification and management of womens health problems and was midwifery-led with general practitioner (GP) contact only if required. Symptom checklists were used at the first home visit, 10 and 28 days, and the Edinburgh Postnatal Depression Scale (EPDS) at 28 days, to maximise identification of problems. This allowed care to be planned, with visit content and frequency flexibly tailored to need, rather than routine. Evidence-based guidelines, including clear GP referral criteria, were developed by the team to assist midwifery management of problems. Care duration was extended, with home visits to 28 days and discharge check at 1012 weeks, the latter also undertaken by the midwife, who again administered the checklist and EPDS.
The primary outcomes were womens health at 4 and 12 months, assessed by the Physical and Mental Component Scores (PCS and MCS) of the Short-Form 36 (SF-36), and the EPDS. Secondary outcomes were womens views about care, reported morbidity at 12 months, health service usage during the year, good practice indicators and health professionals views about care.
At 4 months postpartum the mean MCS and EPDS scores were significantly better in the intervention group and the proportion of women with an EPDS score of 13+ (indicative of probable depression) was lower relative to controls. Mean PCS did not differ. Assessments of womens views about care were either more positive in the intervention group or did not differ.
At 12 months, MCS and EPDS scores remained significantly better among intervention group women. Fewer women in the intervention group reported depression, fatigue and haemorrhoids as present at 12 months in the intervention group, with no differences for other reported morbidities. GP consultation rates during the year were reduced in the intervention group. Secondary care referrals to medical and surgical specialities did not differ. There were more secondary care contacts with professions allied to medicine (PAMs) in the intervention group but more PAM primary care contacts in the control group. Breastfeeding continuation, contraceptive advice and child immunisation did not differ. The intervention midwives were more satisfied with redesigned care than control midwives were with standard care. The GPs and health visitors views about postnatal care did not differ. Intervention care was cost-effective since outcomes were better and costs did not differ substantially.
The redesigned community postnatal care led by midwives and delivered over a longer period resulted in an improvement in womens mental health at 4 months postpartum, which persisted at 12 months and at equivalent overall cost. Subject to consideration and evaluation of local issues of implementation, the evidence would, in the authors opinion, justify this form of care as standard for postnatal women.
It is suggested that further research should focus on: the identification of postnatal depression through screening; whether fewer adverse longer term effects might be demonstrated among the children of the women who had the intervention care relative to the controls; testing interventions to reduce physical morbidity, including studies to validate measures of physical health in postpartum women. Further research is also required to investigate appropriate postnatal care for ethnic minority groups.
MacArthur C, Winter HR, Bick DE, Lilford RJ, Lancashire RJ, Knowles H, et al. Redesigning postnatal care: a randomised controlled trial of protocol-based midwifery-led care focused on individual womens physical and psychological health needs. Health Technol Assess 2003;7(37).
The NHS R&D Health Technology Assessment (HTA) Programme was set up in 1993 to ensure that high-quality research information on the costs, effectiveness and broader impact of health technologies is produced in the most efficient way for those who use, manage and provide care in the NHS.
Initially, six HTA panels (pharmaceuticals, acute sector, primary and community care, diagnostics and imaging, population screening, methodology) helped to set the research priorities for the HTA Programme. However, during the past few years there have been a number of changes in and around NHS R&D, such as the establishment of the National Institute for Clinical Excellence (NICE) and the creation of three new research programmes: Service Delivery and Organisation (SDO); New and Emerging Applications of Technology (NEAT); and the Methodology Programme.
This has meant that the HTA panels can now focus more explicitly on health technologies (health technologies are broadly defined to include all interventions used to promote health, prevent and treat disease, and improve rehabilitation and long-term care) rather than settings of care. Therefore the panel structure was replaced in 2000 by three new panels: Pharmaceuticals; Therapeutic Procedures (including devices and operations); and Diagnostic Technologies and Screening.
The HTA Programme will continue to commission both primary and secondary research. The HTA Commissioning Board, supported by the National Coordinating Centre for Health Technology Assessment (NCCHTA), will consider and advise the Programme Director on the best research projects to pursue in order to address the research priorities identified by the three HTA panels.
The research reported in this monograph was funded as project number 94/22/26.
The views expressed in this publication are those of the authors and not necessarily those of the HTA Programme or the Department of Health. The editors wish to emphasise that funding and publication of this research by the NHS should not be taken as implicit support for any recommendations made by the authors.
Criteria for inclusion in the HTA monograph series
Reports are published in the HTA monograph series if (1) they have resulted from work commissioned for the HTA Programme, and (2) they are of a sufficiently high scientific quality as assessed by the referees and editors.
Reviews in Health Technology Assessment are termed systematic when the account of the search, appraisal and synthesis methods (to minimise biases and random errors) would, in theory, permit the replication of the review by others.
HTA Programme Director: Professor Kent Woods
Series Editors: Professor Andrew Stevens, Dr Ken Stein, Professor John Gabbay, Dr Ruairidh Milne, Dr Chris Hyde and Dr Rob Riemsma
Managing Editors: Sally Bailey and Sarah Llewellyn Lloyd
The editors and publisher have tried to ensure the accuracy of this report but do not accept liability for damages or losses arising from material published in this report. They would like to thank the referees for their constructive comments on the draft document.
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