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Surveillance, Support and Risk in the Postnatal Period
Maria Zadoroznyj
Department of Sociology, Flinders University of South Australia
Abstract
There have been significant changes in the way that maternity services have been organised in recent years. One of the most dramatic has been the significant reduction of time women spend in hospital following childbirth. Yet despite this there has been little debate about whether additional home and community-based support services might be needed for mothers and their newborn infants. At the same time, though, there has been a seemingly parallel occurrence - growing emphasis on the importance of 'early intervention' (including the antenatal as well as the postnatal period) to maximise the health and wellbeing of infants and their mothers. This involves the identification of 'at risk' families and children, and service provision or surveillance that is home or community-based.
Two recently implemented strategies in South Australia target maternal and child health in the postnatal period. One is a local program which provides home-based support (the 'Mothercarer' program). The other is a South Australian government sponsored Universal Home Visiting Program called Every Chance for Every Child. While there are variations in the emphases of the programs, it is suggested that an important trend in policy regarding the postnatal period involves an elision between two kinds of objectives: maternal support in the home, and 'early intervention' to minimise the risk of health and social problems.
Furthermore, it could be argued that risk assessment through surveillance is being seen as at least as important, if not even more important, than the provision of support. Finally, the trend to early discharge, going hand in hand with the emphasis on surveillance of these programs, suggests a loosening of the medicalised appropriation of the postnatal period in favour of a wider social panopticon.
Keywords
sociology, postnatal support and social policy, perinatal surveillance
Article Text
Policy framework: the postnatal period
There is little doubt that childbirth in the twentieth century had become emblematic of the phenomenon of medicalisation, with ever increasing rates of medical intervention defining the event as a situation of inherent risk requiring technological management (Lane 1995, Tew 1990). The postnatal period was not exempt from this medicalisation. Not only did childbirth increasingly take place in the medical setting of the hospital, it was followed by a period of 'lying in', sometimes for a period of weeks, during which time the condition of mother and baby were monitored by midwives and medical staff (McCalman 1998). Mothers were physically taken care of, and of course were encouraged to feed and regulate their newborn's behaviour according to the dominant dictates of the time (Leavitt 1986). In the latter decades of the twentieth century, broader political and economic policies such as economic rationalism exerted a sustained challenge, albeit indirectly, on some aspects of medicalisation. For example, these policies militated against the economic drain of such lengthy hospitalisation, especially for what many were declaring to be a 'normal physiological process'. It is noteworthy, then, that despite the progressive medicalisation of birth, competing pressures are evident in the way that the postnatal period has become constructed, managed and understood. In this paper several of the current initiatives involving postnatal interventions, particularly in South Australia (SA), are described and analysed.
Early discharge
The most obvious 'counter-trend' to the medicalisation of birthing is evident in the length of time women remain in hospital following childbirth. Indeed, the average length of postnatal stay in hospital has declined dramatically in a relatively short period of time. From a standard lying-in period of between 8 and 14 days in the 1950s, the average length of stay for uncomplicated vaginal births has been reduced to 2 or 3 days in Australia, Canada, the UK, US and Sweden (Brown et al 2002). In Australia, the decline in length of hospital stay continued apace through the 1990s; by 2000 the average length of stay was 3.7 days, having declined from 5.3 days in 1991. In 2000, 11.4% of mothers were discharged less than 2 days after delivery compared with 3.2% in 1991 (AIHW NPSU 2003: 20).
Significant reductions in the length of hospital stays following childbirth have also been reported in a large number of other Western countries including Canada, Switzerland, the UK and the US (Brown et al 2004, D'Amour et al 2003, Boulvain et al 2004, Dowsell et al 1997, Dato et al 2000). This trend raises a number of important issues.
The question that has dominated much of the research literature regards the impact of early discharge on maternal and infant health and well-being. Proponents of reduced length of hospital stay and early discharge include in its advantages cost savings for both publicly funded health care systems as well as for third party insurers (Shorten 1995, Dana & Wambach 2003). A shorter postnatal stay has also been promoted as a way of reclaiming childbirth as a normal physiological family life event, thus promoting bonding and a more restful home environment (Waldenstrom 1987, Boulvain et al 2004). Conversely, it has been suggested that without appropriate support structures for home care, these outcomes may not be achievable, and indeed adverse outcomes may result (Boulvain et al 2004, Heck et al 2004, Brown et al 2002).
Early discharge and social stratification
The evidence from Australia and other countries, such as the US where private, third party insurers account for a significant share of the health sector economy, indicates that early postpartum discharge is by no means equally distributed across population groups (Lichtenstein et al 2004). In Australia, the factors associated with shorter periods of postnatal hospital stay were younger maternal age, higher parity, Indigenous status, spontaneous delivery, and, importantly, absence of private health insurance status (AIHW NPSU 2003: 21). Australian mothers who had private insurance status had an average postnatal stay of 5 days, compared with 3.1 days for those with public hospital status. Furthermore:
'...the proportion of hospitalised mothers with a postnatal stay of less than 5 days was 39.6% for those with private status, less than half the proportion of mothers (84.8%) with public status. Differences between public and private categories were apparent for all maternal ages, parity, Indigenous status, type of delivery and size of hospital groups. For mothers having their first baby, 79.1% in the public category stayed for less than 5 days compared with 29.0% in the private category' (AIHW NPSU 2003: 21)
So, importantly, it is clear that economic rationalist, user-pays approaches are exacerbating social differentiation in terms of the duration of access to hospital services. What, then, is happening in terms of support in the home given the reduced hospital stays?
Systems of home-based postnatal support - an international overview
As noted earlier, the research evidence regarding the impact of early discharge is equivocal. One reason for the diverse range of findings is the heterogeneity of systems of home support across sites. In some countries such as the UK and the Netherlands, early discharge is supported by well established programs of postnatal home care from midwives who often provide daily home visits for up to 7 days or more (Twaddle et al 1993, Dowswell et al 1997, Morrell et al 2000). In the Netherlands, the only industrialised country in which a large proportion of obstetric and postnatal care occurs in the home (Hingstman 1994), midwives as well as home care assistants (Kramzorgs) provide maternal and infant care, with the Kramzorgs spending several days in women's homes providing assistance with household duties (Kerssens 1994, van Teijlingen 1990).
In contrast, countries such as the US, Canada and Australia have somewhat less well developed systems for home based postnatal care, and indeed a variety of different protocols exist. In North America, home support may simply involve a telephone call with referrals as necessary or a telephone call followed by one, or occasionally more home visits (Dana & Wambach 2003, Gagnon et al 1997, Gazmararian & Solomon 1997). Many Australian institutions now offer one or more domiciliary visits from professional midwives following discharge from hospital, but rarely is more general domestic help along the lines of the Dutch 'Kramzorg' included in the model of postnatal care for women following discharge from hospital.
While there is a significant research literature in the medical and nursing fields regarding the health outcomes of early discharge for mothers and babies, there has been little sociological examination of its social significance in a broader policy context, particularly given the socio-demographic implications noted above for social inequalities being exacerbated and entrenched.
Conclusion
What is the net result of the kinds of changes in policy described above for postnatal women? They suggest two kinds of implications: one is in terms of further entrenching, rather than reducing the well documented social differentiation in health outcomes. The second suggests a weakening of the medicalisation of this particular period of the life course.
In relation to the first of these, as already indicated, middle class women with private health insurance are least likely to be discharged early and to that extent are least susceptible to the possible detrimental impacts of early discharge. For women without private health insurance, shorter lengths of hospital stay are likely, and hence support with domestic and infant management tasks needs to be found elsewhere. In its current form, a home visit from CYH nurse up to a month (possibly longer) after discharge from hospital is unlikely to have a significant impact on the provision of support to new mothers. Programs such as the Mothercarer service are far more likely to provide meaningful support to postnatal women and their families, and as discussed, the South Australian example provides support to women least well resourced in social and economic terms. However, such programs are currently quite rare.
The net effect of the combination of economic rationalist policies of 'de-institutionalisation' and 'the early years' social ecological orientation has been to de-emphasise the medical monitoring and management of the postnatal period (traditionally seen as up to 6 weeks following the birth of a baby). For women without private health insurance and socially disadvantaged women, the likely result is that they will fall outside the medical gaze more quickly than others in the postnatal period. However, they fall under the surveillance of other, 'early years' focussed policies.
In a temporal sense, the focus of State and federal interventions is now on a wide timeframe that can include the antenatal period and up to 12 years afterwards. In terms of substantive orientation and scope, current policies de-emphasise the physiological health of the mother, and focus on the character of social relationships that are the context of the child's neuropsychological development. So, this period of life is no longer a medicalised phenomenon, where the health of both mother and baby were at the centre of policy. Rather, the postnatal period has become a child-centred crucible of risk.
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