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RESEARCH ARTICLE
Factors that influence uptake of routine
postnatal care: Findings on women’s
perspectives from a qualitative evidence
synthesis
Emma SacksID
1
*, Kenneth Finlayson
2
, Vanessa Brizuela
3
, Nicola Crossland
2
,
Daniela Ziegler
4
, Caroline Sauve
´ID
4
, E
´tienne V. Langlois
5
, Dena Javadi
6
, Soo Downe
2
,
Mercedes Bonet
3
1Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, United
States of America, 2School of Community Health and Midwifery, University of Central Lancashire, Preston,
United Kingdom, 3Department of Reproductive Health and Research, World Health Organization, Genève,
Switzerland, 4Centre Hospitalier de l’Universite de Montreal, Montreal, Canada, 5Partnership for Maternal,
Newborn, and Child Health, World Health Organization, Genève, Switzerland, 6Department of Social and
Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of
America
*esacks@jhu.edu
Abstract
Background
Effective postnatal care is important for optimal care of women and newborns–to promote
health and wellbeing, identify and treat clinical and psychosocial concerns, and to provide
support for families. Yet uptake of formal postnatal care services is low and inequitable in
many countries. As part of a larger study examining the views of women, partners, and fami-
lies requiring both routine and specialised care, we analysed a subset of data on the views
and experiences of women related to routine postnatal care.
Methods
We undertook a qualitative evidence synthesis, using a framework analysis approach. We
included studies published up to December 2019 with extractable qualitative data, with no
language restriction. We focused on women in the general population and their accounts of
routine postnatal care utilization. We searched MEDLINE, PUBMED, CINAHL, EMBASE,
EBM-Reviews, and grey literature. Two reviewers screened each study independently;
inclusion was agreed by consensus. Data abstraction and scientific quality assessment
were carried out using a study-specific extraction form and established quality assessment
tools. The analysis framework was developed a priori based on previous knowledge and
research on the topic and adapted. Due to the number of included texts, the final synthesis
was developed inductively from the initial framework by iterative sampling of the included
studies, until data saturation was achieved. Findings are presented by high versus low/mid-
dle income country, and by confidence in the finding, applying the GRADE-CERQual
approach.
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OPEN ACCESS
Citation: Sacks E, Finlayson K, Brizuela V,
Crossland N, Ziegler D, Sauve
´C, et al. (2022)
Factors that influence uptake of routine postnatal
care: Findings on women’s perspectives from a
qualitative evidence synthesis. PLoS ONE 17(8):
e0270264. https://doi.org/10.1371/journal.
pone.0270264
Editor: Hannah Tappis, Jhpiego, UNITED STATES
Received: September 20, 2021
Accepted: June 7, 2022
Published: August 12, 2022
Copyright: ©2022 Sacks et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the paper and its Supporting information
files.
Funding: Funding was provided by the UNDP/
UNFPA/UNICEF/WHO/World Bank Special
Programme of Research, Development and
Research Training in Human Reproduction (HRP),
Department of Reproductive Health and Research,
World Health Organization, Geneva, Switzerland.
Competing interests: The authors have declared
that no competing interests exist.
Findings
Of 12,678 papers, 512 met the inclusion criteria; 59 articles were sampled for analysis. Five
themes were identified: access and availability; physical and human resources; external
influences; social norms; and experience of care. High confidence study findings included
the perceived low value of postnatal care for healthy women and infants; concerns around
access and quality of care; and women’s desire for more emotional and psychosocial sup-
port during the postnatal period. These findings highlight multiple missed opportunities for
postnatal care promotion and ensuring continuity of care.
Conclusions
Factors that influence women’s utilization of postnatal care are interlinked, and include
access, quality, and social norms. Many women recognised the specific challenges of the
postnatal period and emphasised the need for emotional and psychosocial support in this
time, in addition to clinical care. While this is likely a universal need, studies on mental health
needs have predominantly been conducted in high-income settings. Postnatal care pro-
grammes and related research should consider these multiple drivers and multi-faceted
needs, and the holistic postpartum needs of women and their families should be studied in a
wider range of settings.
Registration
This protocol is registered in the PROSPERO database for systematic reviews:
CRD42019139183.
Background
Postnatal care (PNC) is a fundamental component of the maternal, newborn and child care
continuum, and contributes to reducing maternal and neonatal morbidity and mortality and
improving overall health and wellbeing [1–3]. It is generally defined as the care provided dur-
ing the postnatal period, beginning immediately after childbirth and up to six weeks (42 days)
after birth [1] or beyond [4]. PNC represents a set of healthcare services designed to promote
the health of women and newborns; it includes risk identification, preventive measures, health
education and promotion, and management or referral for complications. Postnatal care not
only improves mortality and clinical care, but also affects the satisfaction and experience of
health care users; understanding the experiences and needs of women and their families with
regard to postnatal care can improve utilization and positive experiences. The World Health
Organisation (WHO) recommends that all women and newborns receive postnatal care in the
first 24 hours following childbirth, regardless of where the birth occurs, and subsequent post-
natal check-ups in the first six weeks [5].
Nevertheless, postnatal care ranks among the lowest coverage of maternal and child health
services interventions; after facility discharge, only 31% of women and 13% of newborns
receive a postnatal check [6,7]. Previous studies have also identified important socioeconomic
and geographic inequities in access to and utilisation of postnatal care services [8].
Over the last two decades, there have been multiple contributions to a large and growing
canon of literature on facilitators and barriers to maternity care, including recent systematic
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Abbreviations: LMIC, Low- or Middle-Income
Countries; MeSH, Medical Subject Headings; PNC,
Postnatal Care; PRISMA, Preferred Reporting
Items for Systematic Review and Meta-Analyses;
WHO, World Health Organisation.
reviews [9–11]. However, most of these studies have focused on care-seeking for intrapartum
care and immediate PNC (within 24 hours), and not later (e.g. post discharge) postnatal care
[12–14]. Much of the literature on maternity care focuses on facilitators and barriers to utiliza-
tion [15–18] but, as low quality care has recently been associated with a potentially higher
attributable risk of mortality than lack of access [19], studies have begun to examine perceived
and actual quality of care, including disrespect and abuse at facilities, as contributing factors to
low utilisation of maternal health services [15–18]. Very few studies have examined the impact
of mistreatment or disrespect of newborns as discouraging factors for uptake of postnatal care,
but recent studies have demonstrated the importance of satisfaction with maternal and neona-
tal care on subsequent care utilization [20,21].
This paper presents the results of a sub-set of the data from a qualitative evidence synthesis
designed to explore the views and experiences of women, their partners, families and commu-
nities in the postnatal period, and factors that influence uptake of routine postnatal care. For
this analysis, our aim was to assess the views and experiences of women in the general popula-
tion in accessing routine postnatal care for themselves and their infants.
Methods
We included qualitative or mixed-methods studies where the focus was the views of women in
the general population (i.e. excluding sub-populations such as adolescents or migrants) on fac-
tors that influence uptake of routine postnatal care (i.e. those without additional postnatal
needs due to comorbidities or identified medical risk), irrespective of parity, mode of delivery,
or place of delivery. Qualitative studies and mixed methods studies were those that included a
qualitative component, either for design (i.e. ethnography, phenomenology), data collection
(i.e. focus groups, interviews, observations, diaries, oral histories), or analysis (i.e. thematic
analysis, framework approach, grounded theory).
A framework approach was used to inductively develop initial themes [22] and thematic
synthesis [23] and was then used iteratively based on the initial thematic framework. Study
assessment included the use of a validated quality appraisal tool [24]. Confidence in the find-
ings was assessed using the GRADE-CERQual tool [25].
Definitions
We define the postnatal period as the time between birth, including the immediate postpartum
period (first 24 hours after birth), and up to six weeks (42 days) after birth [1]. This period var-
ies cross-culturally, but usually coincides with confinement periods and other cultural prac-
tices in the 30–45 days following birth.
We define ‘routine postnatal care’ as formal service provision that is specifically designed to
support, advise, inform, educate, identify those at risk and, where necessary, manage or refer
women or newborns, to ensure optimal transition from childbirth to motherhood and child-
hood. Postnatal care can include a wide range of activities, including risk identification (assess-
ments, screening), prevention of complications, health education and promotion (infant
feeding and care, life-skills education, postpartum family planning, nutrition, vaccines, mental
health support, and prevention and management of harmful practices—including smoking
and alcohol—and violence) and support for families. Routine postnatal care does not typically
include specialist services for comorbidities, address social needs, or the management of con-
ditions not related to pregnancy or postpartum care, though referrals can be made for such
services as a result of routine postnatal care.
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Reflexive statement
Our study team included a medical doctor, a midwife, epidemiologists, public health research-
ers, and librarians, all with extensive experience in the provision and study of maternal and
neonatal healthcare. We began this study with anecdotal and experiential knowledge that post-
natal care is very often unavailable or inadequate, with minimal emphasis on the psychosocial
needs. We believed PNC to be poorly and inequitably accessible, even in high-income settings,
and especially in low- and middle-income countries (LMICs), and that due to perceived or
actual poor quality care, including potential fears of mistreatment, and services not being user-
friendly, families may be discouraged from seeking care. Multiple members of our study team
have been involved in the direct provision of postnatal care, and in developing national and
international guidelines for postnatal care.
Search strategy
The search strategy was developed with senior librarians based on the following concepts: bar-
riers and limitations, postnatal care, and health services needs and demands. The search was
limited to qualitative and mixed-methods studies (see S1 Appendix). Databases searched
included MEDLINE (OVID), PubMed, CINAHL (EBSCO), EMBASE (OVID), and EBM-Re-
views (OVID), as well as a search for grey literature. The search strategy covered papers pub-
lished from inception through December 2019. There were no language restrictions. Hand
searching was used to identify grey literature documents on the following websites: BASE (Bie-
lefeld University Library), OpenGrey, and on the World Health Organization. Duplicates were
excluded through the EndNote X9 software using a method developed by Bramer et al. [26]
Inclusion and exclusion criteria are presented in Table 1.
Study selection
We collated records into Covidence software, excluded duplicates, and screened records based
on title and abstract. To check for consistency, two members of the study team independently
screened the titles and abstracts against the a priori inclusion/exclusion criteria and excluded
irrelevant records. Before assessment of the full-texts of papers, records were categorised as
follows:
1. Either “general population” or sub-populations such as adolescents, migrants
2. “Women’s view’s only”, “partners and family views only”, or “women’s, and partner/family
views”.
3. Either high-income (HIC) or low or middle-income (LMIC) country setting, using the
2019 World Bank Classification Scheme.
In accord with the global nature of the review, and to ensure sufficient representation of
country levels especially lower income settings, we divided the studies into either HIC or
LMIC for sampling. Due to the very large number of eligible papers, 40 papers (~15%) from
each geographic group (HIC or LMIC) were randomly sampled at a time, and screening and
extraction was conducted until it was agreed by consensus that thematic saturation was
reached for each geographic group, at which point 10 additional papers were selected from
each group for confirmatory analysis (if saturation was not, 20 more papers were selected for
that group, until it was agreed that saturation was reached, at which point a confirmatory set
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was then selected). Prior to undertaking this process, it was agreed that, if no further themes
were identified after confirmatory analysis, the group was considered saturated.
Extraction of data and assessment of quality was conducted for each eligible paper by study
team members. Disagreements were settled by consensus among reviewers. Themes from HIC
and LMIC groups were analysed together, which notations made where the specifics or mani-
festation of each theme different between country groups.
Study team members did not assess papers in which they were a co-author. Two of the
included studies were published in a language other than English: a Brazilian study [27] was
analysed by one of the study team members fluent in Portuguese and a Japanese study [28]
was translated by a Japanese-speaker into English prior to analysis. All quotes included in this
manuscript were translated into English by the study authors, the respective study team mem-
bers, or colleagues who assisted with translation.
Papers which did not meet either the general or specific inclusion criteria upon full review
were either excluded or put aside to be evaluated separately for future analysis. Studies which
did not include first-hand reports of women’s experiences were excluded; studies which
focused exclusively on a sub-population (e.g. young adolescent mothers) were put aside for
separate subsequent analysis.
Table 1. Inclusion and exclusion criteria.
Inclusion criteria for overall study Exclusion criteria for overall study
• Studies including healthy women, and/or their
partners/families who were considered to be healthy
in the postnatal period, and who have had a healthy
newborn
• Studies reporting on views/experiences of, or access to,
maternity or intrapartum services generally with no
specific data on postnatal care
• Studies where at least some of the extractable data are
women’s, and/or their partners/families, own
accounts of their views and experiences of the nature
of, provision of, and/or seeking of postnatal care,
irrespective of parity, mode of birth, or place of birth
• Women with known complications/health conditions
(e.g. depression), or after severe morbidity (e.g. near-
miss)
• Services for specific conditions (e.g. HIV), or high-risk
populations (e.g. multiples, preterm, low birth weight,
malformations)
• Studies involving postnatal care experiences with or
without interaction with the health system but
relating to health care (home-based, community-
based care, care by family members)
• Specific interventions for a singular condition (e.g
breastfeeding support, family planning, mental health)
or postnatal education only (e.g. parenting education)
• Studies from high-, middle- and low-income
countries
• Studies related to care of postnatal complications or
intensive care for women or newborns
• Mixed-methods studies reporting qualitative data
without using a recognised qualitative approach to data
collection or analysis
• Case studies, conference abstracts, or unpublished PhD
or Masters’ theses
• Systematic reviews (although reference lists were
reviewed)
• Evaluations of context-specific intervention programs
Additional inclusion criteria for the current analysis
on women’s views on routine postnatal care
Additional exclusion criteria for the current analysis on
women’s views on routine postnatal care
Inclusion Exclusion
• Studies including healthy women, who have had a
healthy newborn in the preceding year
• Studies focused on particular groups of women and
girls, such as migrants or adolescent-only studies
• Studies including womens’ own accounts (not
reported only through a third party)
• Very low quality papers
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Data extraction and analysis
Data extraction, analysis and quality appraisal proceeded concurrently and broadly followed
the ‘best fit’ framework approach described by Carroll [22]. Based on previous related reviews
of antenatal care [29] and intrapartum care [30] as well as a recent thematic synthesis of ‘what
matters to women’ during the postnatal period [31] we used a deductive approach to develop a
thematic framework comprising four broad concepts (Resources and access; Behaviours and
attitudes; External influences; What women want and need) as well as a number of sub-themes
(see S2 Appendix). We then used thematic synthesis techniques [23] to confirm our a priori
framework, or to develop new themes where emerging data failed to fit. We began by using an
Excel spreadsheet to record pertinent details from each study (e.g. author, country, publication
date, study design, setting and location of birth, setting and location of postnatal care, sample
size, data collection methods, participant demographics, contexts, study objectives). The four
concepts from our a priori framework were added to the Excel sheet and the author-identified
findings from each study were extracted (along with supporting quotes) and mapped to the
framework as appropriate. Any codes which did not map to the framework were placed in a
section marked ‘other’ to allow for the emergence of new sub-themes or concepts. This process
included looking for what was similar between papers and for what contradicted (‘discon-
firms’) the emerging themes. For the disconfirming process we consciously looked for data
that would contradict our emerging themes, or our prior beliefs, and views related to the topic
of the review.
Quality assessment
Included studies were appraised using an instrument developed by Walsh and Downe [32]
and modified by Downe et al. [33]. Studies were rated against 11 pre-defined criteria [33],
and then allocated a score from A–D (including + and -), where A+ was the highest and D-
the lowest (see Table 2). Studies rated with a D were excluded from further data analysis.
Studies were appraised by each reviewer independently and a 10% sample was cross-
checked by a different study team member to ensure consistency. Each reviewer was asked
to extract and assess both LMIC and HIC papers in order to increase intra-rater reliability
between the two geographic groups. Any studies where there were scoring discrepancies of
more than a grade were referred to another study team member for moderation.
Once the framework of descriptive themes (or review findings) was agreed by the study
team, the level of confidence in each review finding was assessed using the GRADE-CERQual
tool [34] and agreed by consensus between two study team members. GRADE-CERQual
assesses the methodological limitations and relevance to the review of the studies contributing
to a review finding, the coherence of the review finding, and the adequacy of data supporting a
review finding. Based on these criteria, review findings were graded for confidence using a
Table 2. Ratings for quality assessments of studies.
• A represented a study with no, or few flaws, with high credibility, transferability, dependability and
confirmability.
• B, a study with some flaws, unlikely to affect the credibility, transferability, dependability and/or confirmability of
the study.
• C, a study with some flaws that may affect the credibility, transferability, dependability and/or confirmability of
the study.
• D, a study with significant flaws that are very likely to affect the credibility, transferability, dependability and/or
confirmability of the study.
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classification system ranging from ‘high’ to ‘moderate’ to ‘low’ to ‘very low’. Following CERQ-
ual assessment the review findings were grouped into higher order analytical themes and the
final framework was agreed by consensus amongst the study team.
Results
Papers included in overall study and analytic sample
Our systematic searches yielded 12,678 records, of which 17 were duplicates. An additional
12,149 were excluded by title and by abstract, leaving 602 for full text review (See Fig 1).
Our final list of articles for the analytic sample included 59 studies with views from women
in the general population on routine postnatal care, with 32 coming from HICs and 27 from
LMICs. Specifically, of the LMIC studies, 6 were from low income countries, 12 from lower-
middle income countries, and 9 from upper-middle income countries. The global representa-
tion of studies was reasonably wide with 17 coming from Europe, 13 from Africa, 10 from
North America, 9 from Asia, 4 from the Middle East, 4 from Australasia, and 2 from South
America. The two South American studies were both from Brazil and, although we actively
searched our entire database for studies from other Latin American countries, no others ful-
filled our inclusion criteria. The studies were generally of good quality with an average quality
rating of B and were mainly qualitative and descriptive in design. A full list of the included
studies with relevant characteristics is shown in Table 3.
Findings
This process generated 20 review findings. Following discussions amongst the study team,
these descriptive themes were then mapped against our a priori framework themes to generate
our final analytical themes. Resources and Access was split into two separate themes: Access and
Availability and Physical and Human Resources. We changed Behaviours and Attitudes to
Social Norms to better reflect the larger group of stakeholders influencing maternal choice or
behaviour, and we changed the title of What Women Want and Need to Experience of Care to
better reflect the experiential nature of the findings.
Our analysis reinforced some aspects of the themes in our a priori framework and modified
or expanded others. This final framework includes twenty-one themes and five overarching
study findings: Access and Availability; Physical and Human Resources; External Influences;
Social Norms; and Experience of Care. Our final framework displaying the analytical themes
and descriptive themes, with their associated CERQual gradings, is shown in Table 4.
Themes identified from included studies
Access and availability. Whilst proximity to a health facility appeared to encourage
engagement with maternity providers, our evidence suggests that, for some women living in
remote or rural areas, a lack of transport or the poor quality of transport networks limited
attendance at postnatal clinics. This was compounded in situations where women did not have
the personal resources to pay for relatively expensive journeys to health facilities and/or could
not afford to take time away from their work or family. Even in high income settings where
access to postnatal services is ostensibly free at point of care, the additional costs associated
with attendance including insurance levies, childcare costs, and transport costs limited engage-
ment for women living in poverty.
For accessing postnatal care post-discharge from a health facility after birth, women wanted
a wide range of possible options and flexible schedules for reaching healthcare workers.
Women generally valued the ability to contact providers at convenient times even more so
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than having a large number of contacts. Women wanted to be able to get support during
moments of high stress, or on their schedules, rather than on a pre-defined health systems
schedule, and many referenced the value of their time. Women expressed frustration about
not being able to reach healthcare workers when needed. Service providers that were able to
Fig 1. Flow diagram of included papers.
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Table 3. Characteristics of included studies, alphabetical by study first author.
Author(s) and Study Year Country and
income level
Setting (urban/
rural) health
facility/
community/home
Research Design Participants Quality
rating
Abushaikha L, Khalaf I. Exploring the
Roles of Family Members in Women’s
Decision to Use Postpartum Healthcare
Services from the Perspectives of Women
and Health Care Providers [35]
2014 Jordan
(Upper
middle)
Urban Qualitative and descriptive 24 women in 3 focus groups C
Community based
Alyahya MS, Khader YS, Batieha A,
Asad M. The quality of maternal-fetal
and newborn care services in Jordan:a
qualitative focus group study [36]
2019 Jordan
(Upper
middle)
Unclear Qualitative and descriptive 52 women in 12 focus groups B
Facility based
Aston M, Price S, Monaghan J, Sim M,
Hunter A, Little V. Navigating and
negotiating information and support:
Experiences of first-time mothers [37]
2018 Canada
(High)
Urban and rural. Qualitative and analysed
using feminist theory and
discourse analysis
19 Self-identified first-time mothers
within 12 months of birth/adoption
A
Community based
Aune I, Dahlberg U, Ingebrigtsen O.
Parents’ experiences of midwifery
students providing continuity of care
[38]
2012 Norway
(High)
Urban. Qualitative and analysed
using systematic text
condensation
8 women and 5 men (partners) B-
Community and
home
Ayanore MA, Pavlova M, Biesma R,
Groot W. Stakeholders’ views on
maternity care shortcomings in rural
Ghana:An ethnographic study among
women,providers,public,and
quasiprivate policy sector actors [39]
2017 Ghana (Lower
middle)
Rural. Qualitative using
ethnographic approach
90 women in 9 focus groups plus
interviews with providers and policy
actors
C+
Facility and
community
Baker SR, Choi PYL, Henshaw CA, Tree
J. I felt as though I’d been in jail’:
women’s experiences of maternity care
during labour,delivery and the
immediate postpartum [40]
2005 United
Kingdom
(High)
Unclear. Qualitative and descriptive 24 primiparous women B
Facility based
Beake S, McCourt C, Bick D. Women’s
views of hospital and community-based
postnatal care:the good,the bad and the
indifferent [41]
2005 United
Kingdom
(High)
Urban. Qualitative and descriptive 22 women B
Facility and
community
Bhattacharyya S, Issac A, Rajbangshi P,
Srivastava A, Avan BI. “Neither we are
satisfied nor they”-users and provider’s
perspective:a qualitative study of
maternity care in secondary level public
health facilities,Uttar Pradesh,India
[42]
2015 India (Lower
middle)
Unclear. Qualitative and descriptive 24 women A
Facility based
Cronin C, & McCarthy G. First-time
mothers—identifying their needs,
perceptions and experiences [43]
2003 Ireland
(High)
Urban. Qualitative and descriptive 13 women C
Facility based
Dahlberg U, Haugan G, Aune I.
Women’s experiences of home visits in
the early post-natal period [44]
2016 Norway
(High)
Urban. Qualitative and analysed
using systematic text
condensation
24 women in 6 focus groups B-
Home based
Diamond-Smith N, Thet MM, Khaing
EE, Sudhinaraset M. Delivery and
postpartum practices among new
mothers in Laputta,Myanmar:
intersecting traditional and modern
practices and beliefs [45]
2016 Myanmar
(Lower
middle)
Urban and rural. Qualitative using grounded
theory approach
24 women (plus 10 male partners and
10 grandmothers)
B+
Home based
(Continued)
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Table 3. (Continued)
Author(s) and Study Year Country and
income level
Setting (urban/
rural) health
facility/
community/home
Research Design Participants Quality
rating
Forster DA, McLachlan HL, Rayner J,
Yelland J, Gold L, Rayner S. The early
postnatal period:exploring women’s
views,expectations and experiences of
care using focus groups in Victoria,
Australia [46]
2008 Australia
(High)
Urban and rural. Qualitative and descriptive 50 women (and 2 male partners) B
Facility and home
Frei IA, & Mander R. The relationship
between first-time mothers and care
providers in the early postnatal phase:an
ethnographic study in a Swiss postnatal
unit [47]
2011 Switzer-land
(High)
Unclear. Qualitative using
ethnographic approach
10 primiparous women A
Facility based
Gaboury J, Capaday S, Somera J,
Purden M. Effect of the Postpartum
Hospital Environment on the
Attainment of Mothers’ and Fathers’
Goals [48]
2017 Canada
(High)
Unclear. Qualitative and descriptive 10 women (and 8 male partners) A
Facility based
Gupta ML, Aborigo RA, Adongo PB,
Rominski S, Hodgson A, Engmann CM,
Moyer CA. Grandmothers as
gatekeepers?The role of grandmothers in
influencing health-seeking for mothers
and newborns in rural northern Ghana
[49]
2015 Ghana (Lower
middle)
Rural. Qualitative and descriptive 72 interviews including 35 with
women plus 8 Focus groups with 81
grandmothers
C+
Facility,
community and
home
George L. Lack of Preparedness:
Experiences of First-Time Mothers [50]
2005 USA (High) Urban. Qualitative using grounded
theory approach
10 primiparous women B
Home based
Henderson V, Stumbras K, Caskey R,
Haider S, Rankin K, Handler A.
Understanding Factors Associated with
Postpartum Visit Attendance and
Contraception Choices:Listening to
Low-Income Postpartum Women and
Health Care Providers [51]
2016 USA (High) Urban. Qualitative and descriptive 20 mothers and 12 healthcare
providers
A
Facility based
Hindley, J. Having a baby in Balsall
Heath:women’s experiences and views of
continuity and discontinuity of
midwifery care in the mother-midwife
relationship:a review of the findings
from a report of a research project
commissioned by ’Including Women’
[52]
2005 UK (High) Urban. Qualitative and descriptive 20 mothers B
Facility,
community and
home
Hoang H, Le Q, Terry D. Women’s
access needs in maternity care in rural
Tasmania,Australia:a mixed methods
study [53]
2014 Australia
(High)
Rural. Mixed methods using a
survey and semi-structured
interviews
210 women completed the survey and
22 mothers participated in the
interviews
B
Community
Humbert L, Roberts TL. The Value of a
Learner’s Stance:Lessons Learned from
Pregnant and Parenting Women [54]
2009 USA (High) Urban. Qualitative and descriptive 24 focus groups with 143 women
(aged 14–45)–all receiving Medicaid
C+
Facility
Izugbara CO, Wekesah F. What does
quality maternity care mean in a context
of medical pluralism?Perspectives of
women in Nigeria [55]
2018 Nigeria
(Lower
middle)
Urban, Semi-
urban and rural.
Qualitative and descriptive 173 women in total: 16 focus groups
with 130 women and 43 interviews
C+
Facility and
community
(Continued)
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Table 3. (Continued)
Author(s) and Study Year Country and
income level
Setting (urban/
rural) health
facility/
community/home
Research Design Participants Quality
rating
Kanengoni B, Andajani-Sutjahjo S,
Holroyd E. Women’s experiences of
disrespective and abusive maternal
healthcare in a low resource rural setting
in eastern Zimbabwe [56]
2019 Zimbabwe
(Lower
middle)
Rural. Qualitative and descriptive 20 women, 8 participated in
interviews and another 12 in 2 focus
groups
C
Facility based
Khalaf IA. Jordanian women’s
perceptions of post-partum health care
[57]
2007 Jordan
(Upper
middle)
Unclear. Qualitative and descriptive 24 women in 3 focus groups C+
Facility based
Kirca N & Ozcan S. Problems
Experienced by Puerperants in the
Postpartum Period and Views of the
Puerperants about Solution
Recommendations for these Problems:A
Qualitative Research [58]
2018 Turkey
(High)
Urban. Qualitative and descriptive 24 interviews with women C
Facility and
community
Kurth E, Kra¨henbu¨hl K, Eicher M,
Rodmann S, Fo¨lmli L, Conzelmann C,
Zemp E. Safe start at home:what
parents of newborns need after early
discharge from hospital–a focus group
study [59]
2016 Switzerland
(High)
Urban and rural. Qualitative using a ‘playful’
design (creating symbolic
structures and images with
plastic bricks)
24 participants in 6 focus groups
including 20 women and 4 male
partners
A-
Facility and
community
Kurth E, Spichiger E, Zemp Stutz E,
Biedermann J, Ho¨sli I, Kennedy HP.
Crying babies,tired mothers—challenges
of the postnatal hospital stay:an
interpretive phenomenological study [60]
2010 Switzerland
(High)
Urban. Qualitative using
interpretive
phenomenology
15 women of diverse parity and
educational backgrounds
A-
Facility based
Leirbakk MJ, Torper J, Engebretsen E,
Opsahl J N, Zeanah P, Magnus JH.
Formative research in the development
of a salutogenic early intervention home
visiting program integrated in public
child health service in a multi-ethnic
population in Norway [61]
2018 Norway
(High)
Urban. Qualitative using a
formative approach
utilizing data from multiple
sources
18 women in 5 focus groups B
Community and
home
Lewis L. Postnatal clinics:Midwives and
women’s experiences [62]
2009 UK (High) Urban. Qualitative and descriptive 8 postnatal women (and 6 community
midwives)
B
Community based
McCarter D, Macleod CE. What Do
Women Want?Looking Beyond Patient
Satisfaction [63]
2016 USA (High) Urban. Qualitative and descriptive 20 women of various parities
(including several first-time mothers)
plus 2 couples expecting their first
child
C+
Facility based
Memon Z, Zaidi S, Riaz A. Residual
Barriers for Utilization of Maternal and
Child Health Services:Community
Perceptions From Rural Pakistan [64]
2015 Pakistan
(Lower
middle)
Rural. Qualitative and exploratory Total number not provided. 20 focus
groups with an average of 10 women
with children under age of 5 plus
fathers of children under 5 and
community health workers
C
Facility based
Miteniece E, Pavlova M, Shengelia L,
Rechel B, Groot W. Barriers to accessing
adequate maternal care in Georgia:a
qualitative study [65]
2018 Georgia
(Upper
middle)
Urban and rural. Qualitative and exploratory 60 women, nulliparous and
multiparous, aged 19–42 plus
providers and policy-makers
A
Facility based
Morris JL, Short S, Robson L,
Andriatsihosena MS. Maternal Health
Practices,Beliefs and Traditions in
Southeast Madagascar [66]
2014 Madaga-scar
(Low income)
Urban. Mixed methods including
questionnaires, interviews
and focus groups.
629 in total, 256 in qualitative part of
the study, including 60 women in 6
FGD, and interviews with 10 women
with children less than 1year old
C
Community and
home
(Continued)
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Table 3. (Continued)
Author(s) and Study Year Country and
income level
Setting (urban/
rural) health
facility/
community/home
Research Design Participants Quality
rating
Mrisho M. Obrist B, Schellenberg JA,
Haws RA, Mushi AK, Mshinda H,
Tanner M. Schellenberg D.The use of
antenatal and postnatal care:
perspectives and experiences of women
and health care providers in rural
southern Tanzania [67]
2009 Tanzania
(Lower
middle)
Rural. Qualitative and descriptive 74 women and healthcare workers in
total. Of the total 58 were women and
of these 39 had a young child less than
one year old and 19 were pregnant
B-
Community based
Mrisho M, Schellenberg JA, Mushi AK,
Obrist B, Mshinda H, Tanner M,
Schellenberg D. Understanding home-
based neonatal care practice in rural
southern Tanzania [68]
2008 Tanzania
(Lower
middle)
Rural. Qualitative and descriptive A total of 40 in-depth interviews (5 in
8 villages) and 16 focus groups (5 per
village). Interviews were with
postnatal women, pregnant women
and 8 TBA’s. Focus groups (2 per
village) with 6–8 women who had
given birth at least once
C
Facility and home
Munday R. Women’s experiences of the
postnatal period following a planned
homebirth:A phenomenological study
[69]
2003
(a)
Canada
(High)
Unclear. Qualitative using
interpretive
phenomenology
10 women who planned a homebirth C+
Home based
Munday R. Women’s experiences of the
postnatal period following a planned
homebirth:A phenomenological study
[70]
2003
(b)
Canada
(High)
Unclear. Qualitative using
interpretive
phenomenology
10 women who planned a homebirth C+
Home based
Nakano AMS, Beleza AC, Gomes FA,
Mamede FV. O cuidado no "resguardo":
as vivências de crenças e tabus por um
grupo de puérpera [27].
2003 Brazil (Upper
middle)
Urban. Qualitative and descriptive 20 women C-
Home based
Newbrander W, Natiq K, Shahim S,
Hamid N, Skena NB. Barriers to
appropriate care for mothers and infants
during the perinatal period in rural
Afghanistan:a qualitative assessment
[71]
2014 Afghani-stan
(Low)
Rural. Qualitative and descriptive 30 interviews with women plus 29
focus groups and 15 direct
observations
B-
Home based
Noguchi M, Takahashi N, Fujita W,
Asaka Y, Takamuro N. Perceptions of
women who utilized public postpartum
health care services in Sapporo City,
Japan [72]
2018 Japan (High) Urban. Mixed methods using a
survey and in-depth
interviews
21 interviews with mothers C
Community based
Persson EK, Fridlund B, Kvist LJ, Dykes
AK. Mothers’ sense of security in the first
postnatal week:interview study [73]
2011 Sweden
(High)
Urban. Qualitative and descriptive 10 women in 3 focus groups plus 4
individual interviews (14 women in
total)
A
Facility based
Probandari A, Arcita A, Kothijah K,
Pamungkasari EP. Barriers to utilization
of postnatal care at village level in Klaten
district,central Java Province,Indonesia
[74]
2017 Indonesia
(Upper
middle)
Rural. Qualitative and descriptive 8 mothers with postnatal
complications (plus 6 family
members)
B
Facility and home
based
Puthussery S, Twamley K, Macfarlane
A, Harding S, Baron M. ‘You need that
loving tender care’:maternity care
experiences and expectations of ethnic
minority women born in the United
Kingdom [75]
2010 UK (High) Urban. Qualitative and descriptive 34 mothers of Black Caribbean, Black
African, Indian, Pakistani,
Bangladeshi and Irish descent
B-
Facility based
Raven JH, Chen Q, Tolhurst RJ, Garner
P. Traditional beliefs and practices in the
postpartum period in Fujian Province,
China:a qualitative study [76]
2007 China (Upper
middle)
Urban and rural. Qualitative and descriptive 12 mothers (plus 12 fathers & 12
grandmothers)
B
Home based
(Continued)
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Table 3. (Continued)
Author(s) and Study Year Country and
income level
Setting (urban/
rural) health
facility/
community/home
Research Design Participants Quality
rating
Razurel C, Bruchon-Schweitzer M,
Dupanloup A, Irion O, Epiney M.
Stressful events,social support and
coping strategies of primiparous women
during the postpartum period:a
qualitative study [77]
2011 Switzer-land
(High)
Urban. Qualitative and descriptive 60 first-time mothers B+
Facility,
community and
home
Ribeiro JP, da Costa de Lima FB, da
Silva Soares TM, Oliveira BB, Klemtz
FV, Lopes KB, Hartmann M. Needs Felt
by Women in the Puerperal Period [78]
2019 Brazil (Upper
middle)
Urban. Qualitative and descriptive 20 mothers (10 in the immediate
postpartum and 10 in the ‘remote’
postpartum phase)
C+
Facility based
Rodin D, Silow-Carroll S, Cross-Barnet
C, Courtot B, Hill I. Strategies to
Promote Postpartum Visit Attendance
Among Medicaid Participants [79]
2019 USA (High) Mixed. Analysis of qualitative case
studies from various data
sources
Coded notes from qualitative case
studies including 739 interviews with
1,074 key informants and 133 focus
groups with 951 women
C+
Facility and
community based
Rouhi M, Stirling CM, Crisp EP.
Mothers’ views of health problems in the
12 months after childbirth:A concept
mapping study [80]
2019 Australia
(High)
Urban. Mixed methods–Concept
mapping study
81 mothers B-
Unclear
Sacks E, Moss WJ, Winch PJ, Thuma P,
van Dijk JH, Mullany LC. Skin,thermal
and umbilical cord care practices for
neonates in southern,rural Zambia:a
qualitative study [81]
2015 Zambia
(Lower
middle)
Rural. Qualitative and descriptive
utilizing interviews, focus
groups and observations
36 interviews (24 with mothers) and
39 participants at 5 Focus groups
(including some TBAs)
A
Home and facility
Shaban IA, Al-Awamreha K,
Mohammadb K, Gharaibehb H.
Postnatal women’s perspectives on the
feasibility of introducing postpartum
home visits:a Jordanian study [82]
2018 Jordan
(Upper
middle)
Unclear. Qualitative and descriptive 30 women with healthy newborns
(vaginal or cesarean birth), 17–43
years old, primiparous and
multiparous
B
Home based
Sharkey A, Yansaneh A, Bangura PS,
Kabano A, Brady E, Yumkella F, Diaz T.
Maternal and newborn care practices in
Sierra Leone:a mixed methods study of
four underserved districts [83]
2017 Sierra Leone
(Low)
Rural. Mixed methods utilizing
survey data, interviews and
focus groups
98 Interviews and 15 Focus Groups (8
Focus groups made up of men only)
B-
Community based
Sialubanje C, Massar K, Hamer DH,
Ruiter RAC. Understanding the
psychosocial and environmental factors
and barriers affecting utilization of
maternal healthcare services in Kalomo,
Zambia:a qualitative study [84]
2014 Zambia
(Lower
middle)
Urban and rural. Qualitative and descriptive 141 women in 12 Focus groups, 12
women per FDG except one with 9
women; plus 35 in-depth interviews
with key informants
B
Facility based
Tesfaye G, Chojenta K, Smith R, Loxton
D. Delaying Factors for Maternal Health
Service Utilization in Eastern Ethiopia:
A Qualitative Exploratory Study [85]
2019 Ethiopia
(Low)
Urban and rural. Qualitative and exploratory 20 women (plus 19 mothers-in-law, 13
TBAs, 24 husbands, 12 health
extension officers).
B
Community based
Tully KP, Steube AM, Verbiest SB. The
fourth trimester:a critical transition
period with unmet maternal health
needs [86]
2017 USA (High) Urban. Type of delphi study
utilizing data from various
sources and interviews with
key stakeholders
18 mostly immigrant mothers from
underprivileged urban areas
C
Facility and
community
Waiswa P, Kemigisa M, Kiguli J,
Naikoba S, Pariyo GW, Peterson S.
Acceptability of evidence-based neonatal
care practices in rural Uganda–
implications for programming [87]
2008 Uganda (Low) Rural. Qualitative and descriptive 2 focus groups with young mothers, 4
with older mothers (>30 yrs), 2 focus
groups with fathers, 2 with child
minders (older children up to 13 yrs)
C+
Facility,
community and
home
White PM. Crossing the river:Khmer
women’s perceptions of pregnancy and
postpartum [88]
2002 Cambodia
(Lower
middle)
Rural and urban. Qualitative and descriptive
incorporating ethnographic
approaches
88 participants total, including
mothers, TBAs, and midwives (41
interviews and 11 focus groups)
B-
Community based
(Continued)
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offer more flexible opportunities for engagement like drop-in clinics, telephone contacts, out
of hours services and, in particular, home visits, were viewed more positively.
Physical and human resources. For women in a variety of different settings, the ability to
engage with formal postnatal services was influenced by resource and infrastructure con-
straints, especially in settings where community-based services were limited or non-existent.
The evidence also suggests that the poor availability of resources in some health facilities may
act as a deterrent to women who might otherwise benefit from postnatal care. A lack of basic
medicine and equipment and inadequate or inconsistent water or electricity supplies limited
attendance in some low-income settings. Whilst the availability of essential equipment and
utilities was not reported to be an issue in most high-income countries, women were some-
times aware of staff shortages on postnatal wards and this affected their experience of care.
Women’s perception that some health facilities were understaffed, especially from studies in
LMICs, was also reflected in the length of time they had to wait to be seen by a healthcare pro-
vider. In some instances, this was compounded by cursory and impersonal exchanges with
care providers, leaving women feeling frustrated, annoyed and undervalued.
External influences. Women identified several external influences as having a bearing on
their engagement with postnatal services. These ranged from environmental influences such as
the physical condition of the health facility itself to the availability and affordability of private
providers to a willingness (or otherwise) to engage with traditional postnatal practices, either
in accordance with or against the advice of family and community members.
For women in a variety of different settings and contexts, the condition of postnatal wards
and health facilities was important. Women used words such as ‘clean’ and ‘modern’ to frame
positive perceptions or ‘dirty’ and ‘unhygienic’ to highlight negative experiences. These nega-
tive accounts were more commonly associated with facilities in low-income settings but even
in high income countries women used words like ‘dilapidated’ and ‘unwelcoming’ to describe
postnatal wards. In addition to the condition of the buildings, women also commented on the
Table 3. (Continued)
Author(s) and Study Year Country and
income level
Setting (urban/
rural) health
facility/
community/home
Research Design Participants Quality
rating
Woodward BM, Zadoroznyj M, Benoit
C. Beyond birth:Women’s concerns
about post-birth care in an Australian
urban community [89]
2016 Australia
(High)
Urban. Qualitative and descriptive 15 mothers who had given birth in
different environments
B
Facility,
community and
home
Yeh YC, St John W, Chuang YH, Huang
YP. The care needs of postpartum
women taking their first time of doing
the month:a qualitative study [90]
2017 Taiwan
(High)
Urban. Qualitative and descriptive
utilizing interviews
27 new mothers aged 25–39
interviewed in PNC facility
B
PNC Nursing
facility
Young E. Maternal Expectations:Do
they match experience? [91]
2008 UK (High) Urban. Qualitative and descriptive
utilizing focus groups and
interviews
11 interviews with 1
st
time mothers
aged 24–30 with a range of EPDS
depression scale scores
C
Facility based
Zamawe C, Masache GC, Dube AN. The
role of the parents’ perception of the
postpartum period and knowledge of
maternal mortality in uptake of
postnatal care:a qualitative exploration
in Malawi [92]
2015 Malawi (Low) Rural. Qualitative and descriptive
utilizing focus groups
36 women in three focus groups, 14
men in 1 focus group. All married
farmers. Women 18–25 years, men
between ages of 25 and 35 years.
>50% finished primary education
C
Facility based
TBA: traditional birth attendant.
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Table 4. Review findings and CERQual gradings.
Analytical Theme Review finding Contributing papers Supporting Quote CERQual
Grade
ACCESS &
AVAILABILITY
1. Flexible contact opportunities—Women in included studies
expressed a preference for a wider range of access options as well as
greater flexibility in provider managed appointment systems. The
provision of home visits was valued by these women in a number of
different contexts and the availability of drop-in clinics, out of hours
services, and telephone or online services were also highlighted as
examples of more user-friendly systems.
13 studies (7 HIC; 6 LMIC): Ayanore 2017 (Ghana); Frei 2011
(Switzerland); Henderson 2016 (USA); Hindley 2005 (UK); Hoang
2014 (Australia); Khalaf 2007 (Jordan); Kurth 2010 (Switzerland);
Leirbakk 2018 (Norway) Lewis 2009 (UK); Mrisho, 2009 (Tanzania);
Ribiero 2019 (Brazil); Shaban 2018 (Jordan); Zamawe 2015 (Malawi)
"I feel that the schedule for the visit must be flexible according to each
mother, and the schedule should be determined by the mother and her
health care provider together". [Shaban 2018, Jordan]
Moderate
"I guess if there was someone in a situation where they didn’t have the
support, it was just a single mom and their child, I guess if someone
can come into their home or something, that would probably be really
convenient.” [Henderson 2016, USA]
2. Personal resources: In the included studies, additional costs associated
with transport to and from health facilities, payment for childcare,
healthcare insurance payments, the potential costs of medicines for
mother or newborn as well as the loss of household income associated
with clinic attendance all acted as barriers to PNC engagement.
13 studies (3 HIC, 10 LMIC): Ayanore 2017 (Ghana); Bhattacharyya,
2015 (India); Gupta 2015 (Ghana); Hoang, 2014 (Australia);
Miteniece 2018 (Georgia); Mrisho 2008 (Tanzania); Mrisho 2009
(Tanzania); Newbrander 2014 (Afghanistan); Noguchi 2018 (Japan);
Rodin 2019 (USA); Shaban 2018 (Jordan); Sialubanje 2014 (Zambia);
Zamaw, 2015 (Malawi)
"The clinic is far away, so we cannot get there by walking. We cannot
rent a car to go because there is not enough money, not even 5 Afs [US
$ 0.10], in my husband’s pocket”. [Newbrander 2014, Afghanistan]
Moderate
"The cost of travel was pretty expensive and also trying to organise for
someone to look after my other son because he doesn’t travel well".
[Hoang 2014, Australia]
3. Proximity of health facility: For some women in the included studies,
the convenience of having a health facility close to where they lived
encouraged attendance for postnatal care, but for women living in
predominantly rural areas inadequate transport networks and/or poor
infrastructure acted as a barrier to access.
9 studies (1 HIC, 8 LMIC): Ayanore, 2017 (Ghana); Gupta 2015,
(Ghana); Hoang 2014 (Australia); Miteniece 2018 (Georgia); Mrisho
2009 (Tanzania); Newbrander 2014 (Afghanistan); Tesfaye 2019
(Ethiopia): Waiswa, 2008 (Uganda); Zamawe 2015 (Malawi)
“Distance is an issue for women from rural areas, because in the
capital the care is more adequate and modern than in rural areas.”
[Miteniece 2018, Georgia]
Low
4. Value of women’s time—In a number of settings, the amount of time
women had to wait at a health facility to see a healthcare provider for a
postnatal check-up (regardless of whether they had a timed appointment
or not) was too long and often led to frustration and/or additional
expense. In some instances, this was compounded by cursory exchanges
with healthcare providers, leaving women feeling undervalued and
frustrated.
8 studies (2 HIC, 6 LMIC): Ayanore 2017 (Ghana); Alyahaya, 2019
(Jordan); Hindley, 2005 (UK); Humbert, 2009 (USA); Kanengoni
2019 (Zimbabwe); Newbrander 2018 (Afghanistan); Probandari 2017
(Indonesia); Zamawe 2015 (Malawi)
"The problem with the clinic was that they would make us wait for a
very long time in the queue without being served. They opened at 8 in
the mornings and I am only leaving at 3pm after being served because
there are no midwives there" [Kanengoni 2019, Zimbabwe]
Low
PHYSICAL AND
HUMAN
RESOURCES
5. Physical resources at facilities—Women in all settings represented by
the included studies perceived a deficit, reporting that some health
facilities were under-resourced and, especially in LMICs, also expressed
the unavailability of drugs or equipment and inconsistencies in the supply
of water or electricity to the health facility.
6 studies (2 HIC, 4 LMIC): Bhattacharyya 2015 (India); Forster 2008
(Australia); Izugbara 2018(Nigeria); Mrisho 2009, (Tanzania);
Puthussery 2010 (UK); Waiswa 2008, (Uganda)
“They (sweeper) clean the ward and toilet once a day. But the toilet is
dirty most of the time. Sometimes, women do not pour enough water.
Water supply is also not regular. " [Bhattacharyya, India, 2015]
Low
“So they moved me to another ward, not another ward, just another
area of the ward, but there was no light. And they gave me like a pen
like yours. . . a pen-torch, and that’s what I needed to use to see my
baby to feed my baby”. [Puthussery 2015, UK]
6. Human resources at facilities–Many women in the included studies
reported that health facilities were under-resourced in terms of staff
resulting in limited time for staff to spend with patients
9 studies (5 HIC, 4 LMIC): Ayanore 2017, (Ghana); Baker 2005, (UK);
Beake 2007, (UK); Hindley 2005 (UK); Miteniece 2018, (Georgia);
Mrisho 2009 (Tanzania); Probandari 2017(Indonesia); Puthussery
2010(UK); Tully 2017 (USA)
"You just feel that there was so few midwives to look after so many
women [on the postnatal ward] that they just couldn’t give you the. . .
you know the time that you wanted. . . . " [Hindley 2005, UK 2 UK
quotes]
Low
“Those who go for weight monitoring spend less time at the clinic than
those who go for vaccination. This is because there is one health care
provider; we suggest that there is a need to increase the number of
health care providers” [Mrisho 2009, Tanzania]
(Continued)
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Table 4. (Continued)
Analytical Theme Review finding Contributing papers Supporting Quote CERQual
Grade
EXTERNAL
INFLUENCES
7. Importance of environment—For women in the studies who gave
birth in health facilities the unhygienic, dirty and dilapidated conditions
in some postnatal wards made them feel disappointed, depressed and
occasionally unsafe. For others, not being able to control the often noisy
and disruptive atmosphere on the postnatal ward generated feelings of
frustration and despair, prompting a few to leave earlier than planned.
For women who gave birth at home, the relatively calm and familiar
home environment enabled them to feel more relaxed and in control of
their immediate postnatal experiences.
10 studies (9 HIC, 1 LMIC): Beake, 2005 (UK); Bhattacharyya, 2015
(India); Cronin, 2003 (Ireland); Forster, 2008 (Australia), Frei, 2011
(Switzerland); Gaboury, 2017 (Canada); Munday, 2003a (UK);
Noguchi, 2018 (Japan); Puthussery, 2010 (UK); Woodward, 2016
(Australia).
“I would have liked the whole thing to have happened in a much nicer
environment. [Name of the Maternity unit] is grim to say the least, it’s
Victorian-looking, it’s grey, it’s dark and dull and, having said that, the
staff, the midwives, were fine, were great. . .but the place itself was
quite a depressing place to give birth in and a bit frightening really”
[Puthussery 2010, UK]
Moderate
Facility birth: "I did not have one minute to myself. People were just
coming in all the time’ and if it’s not your visitor, it’s the girl across the
way" [Cronin 2003, Ireland].
Homebirth: "You can go and sit in your witches brew (herbal sits bath)
and not bother about anybody. . .it’s nice just being able to pad around
in the nude if you want to" [Munday 2003b, UK]
8. Influence of traditional practices—In included studies from LMIC
contexts, women preferred to observe traditional (or cultural) practices
relating to postnatal care. For some women this incorporated a variety of
practices (sometimes involving seclusion or isolation) frequently
associated with ’doing the month’; for others it involved the use of
medicines, herbs and spiritual purification under the guidance of a healer
or TBA; and for others the preference to be seen by a local healer or TBA
was born out of trust, convenience and/or economic necessity. In a few
settings women felt conflicted between observing traditional practices
(advocated by influential family members) and the approaches
recommended by healthcare providers.
16 studies (2 HIC, 14 LMIC): Diamond-Smith, 2016 (Myanmar);
Gupta, 2015 (Ghana); Humbert, 2009 (USA); Izugbara, 2018
(Nigeria); Memon, 2016 (Pakistan); Morris, 2014 (Madagascar);
Mrisho, 2008 (Tanzania); Nakano, 2003 (Brazil); Newbrander, 2014
(Afghanistan); Probandari, 2017 (Indonesia); Raven, 2007 (China);
Sacks, 2015 (Zambia); Sharkey, 2017 (Sierra Leone); Tesfaye, 2019
(Ethiopia); Yeh, 2017 (Taiwan); White, 2002 (Cambodia).
". . . The families do not want the women to go out of home before two
months of birth for fear of the evil eye” [Tesfaye 2019, Ethiopia]
Moderate
"Old family members and friends tell us to have traditional food
during this period. We follow their advice because we don’t know
what to do in this period. But if we do follow this diet we still don’t
know if we will have some problems. The doctor gave us some
suggestions, but our parents promoted the traditional way. It is
difficult to make a choice" [Raven 2007, China]
9. Women’s autonomy–In the included studies, women’s decisions to
engage with formal postnatal services was often influenced by key family
members and/or societal norms relating to women’s autonomy and/or
their ability to travel independently. In some settings, the role of
maternity care decision-maker was taken by the mother-in-law,
sometimes with additional influence by the husband. Women’s capacity
to engage with postnatal care was largely dependent on the value these
family members placed on postnatal services.
10 studies (10 LMIC): Abushaikha, 2014 (Jordan); Ayanore, 2017
(Ghana); Diamond-Smith, 2016 (Myanmar); Gupta, 2015 (Ghana);
Kirca, 2018 (Turkey); Mrisho, 2009 (Tanzania); Newbrander, 2014
(Afghanistan); Raven, 2007 (China); Tesfaye, 2019 (Ethiopia);
Waiswa, 2008 (Uganda)
“Mothers-in-law say, ‘We stayed indoors and did not go to doctors for
our problems, so you should not go to doctors’.” [Newbrander 2014,
Afghanistan]
Moderate
"M: How would you know if your baby is sick?
R: I wouldn’t know unless I ask my mother-in-law.
M: How about if it is a convulsion?
R: We will go to clinic but with my mother in-law’s permission"
[Gupta 2015, Ghana]
10. Privacy–In some studies from HIC settings, women’s need for
privacy was sometimes expressed in terms of their inability to engage in
confidential conversations with healthcare providers because of a lack of
space or a lack of sensitivity. In other settings the relatively open nature of
shared postnatal wards left women feeling exposed and vulnerable at a
time when they felt most in need of privacy. For studies on women who
gave birth at home in HIC contexts, the ability to control their
environment to regulate visitor access and periods of rest was viewed in
positive terms.
8 studies (6 HIC, 2 LMIC): Bhattacharyya 2015 (India); Beake, 2005
(UK); Gaboury 2017 (Canada); Humbert 2009 (USA); Khalaf, 2007
(Jordan); Kurth 2010 (Switzerland); Munday 2003b (Canada);
Woodward 2006 (Australia)
“I would not feel comfortable breastfeeding in a shared room with a
curtain” [Gaboury 2017, Canada]
Low
“I’m a private person anyway and I want to be enclosed and everyone
was yanking back the curtains all the time, which I think was a bit
annoying” [Beake 2005, UK]
11. Influence of private PNC provision—In a few settings in the
included studies, women with access to financial resources chose to make
use of private healthcare facilities because they perceived maternity care
to be of higher quality. In some instances, this perception proved to be
unfounded and women were left feeling disappointed by the lack of
postnatal care on offer. In other instances, women were forced to pay for
private treatment because the public hospital did not have the resources
to provide the required level of postnatal care
7 studies (2 HIC, 5 LMIC): Alyahaya, 2019 (Jordan); Forster 2008
(Australia); Izugbara 2018 (Nigeria); Khalaf 2007 (Jordan); Memon
2016 (Pakistan); Probandari 2017 (Indonesia); Woodward 2016
(Australia)
"One of the reasons we went private was because it was a longer stay
and we didn’t feel like two nights was adequate preparation to learn to
take care of a child. . . but I could imagine that with your secondchild
you might want to stay shorter in total” [Forster 2008, Australia]
Very Low
(Continued)
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Table 4. (Continued)
Analytical Theme Review finding Contributing papers Supporting Quote CERQual
Grade
SOCIAL NORMS 12. Value of formal postnatal care—In studies from some LMIC
settings, women did not recognise the need for formal postnatal services
and only visited health facilities when they or their infant became unwell
or experienced complications. Occasionally these priorities were
exacerbated by healthcare providers who either failed to promote
postnatal care practices or devalued the services they offered.
13 studies (13 LMIC): Abushaikha, 2014 (Jordan); Ayanore, 2017
(Ghana); Alyahaya, 2019 (Jordan); Khalaf, 2007 (Jordan); Memon,
2015 (Pakistan); Mrisho, 2008 (Tanzania); Mrisho, 2009 (Tanzania);
Probandari, 2017 (Indonesia); Shaban, 2018 (Jordan) Sialubanje, 2014
(Zambia); Tesfaye, 2019 (Ethiopia); Waiswa, 2008 (Uganda); Zamawe,
2015 (Malawi)
"I have given birth to my first child at home and didn’t visit a health
facility for check-up and nothing happened to the child. So, I don’t
want to waste my time by going there" [Tesfaye 2019, Ethiopia].
Moderate
"I had visited the health centre only once during the postpartum
period because when I went they told me there was no need to visit the
health centre when I was not complaining of anything. So why visit the
health centre?" [Khalaf 2007, Jordan]
13. Trust in the system–In the included studies, women’s willingness to
engage with PNC services was sometimes undermined by a lack of trust
in the system. Women expressed this issue in a number of ways including
the need to provide informal payments or gifts/bribes to ensure quality of
care, a lack of faith in the clinical skills of the provider, the belief that
personal information would not remain confidential and the perception
that disclosure of a mental health issue (like postnatal depression) might
lead to their infant being taken away.
12 studies (1 HIC, 11 LMIC): Alyahaya 2019 (Jordan); Ayanore 2017
(Ghana); Izugbara 2018 (Nigeria); Kanengoni 2019 (Zimbabwe);
Khalaf 2007 (Jordan); Newbrander 2014 (Afghanistan); Probandari
2017 (Indonesia); Shaban 2018 (Jordan); Sialubanje, 2014 (Zambia);
Tully 2017 (USA); Zamawe 2015 (Malawi).
"If you go to the clinic after giving birth at home, nurses make you pay
before they examine your baby" [Sialubanje, Zambia, 2014].
Moderate
"I took my sick child to the government health centre and nobody was
willing to help me. . . they did not even have medicines. Do youknow
they said that if we don’t have up to N6000 ($20), they will not attend
to the child? [Izugbara 2018, Nigeria]
14. Infant-focused PNC—In studies from some settings, new mothers
were of the view that postnatal care services were largely (or only)
directed at the welfare of the infant. Most of these women valued the
services on offer and highlighted immunizations and clinical indicators of
infant development as particularly useful.
8 studies (1 HIC, 7 LMIC): Alyahaya 2019 (Jordan); Henderson 2016
(USA); Khalaf 2007 (Jordan); Mrisho 2009 (Tanzania); Sacks 2015
(Zambia); Shaban 2018 (Jordan); Sialubanje 2014 (Zambia), Waiswa
2008 (Uganda)
“PNC is just for the child. There is nothing for the mother. All other
services that follow soon after birth are for the child.” [Mrisho 2009,
Tanzania].
Low
15. Gender of healthcare providers—In studies from some LMIC
settings, women felt their needs and sensitivities during the postnatal
period were better understood by female health providers and were
sometimes ashamed or embarrassed to be seen by a male healthcare
provider. In one specific context women felt unsafe if they received a
home visit from a male healthcare provider.
5 studies (5 LMIC): Bhattacharyya 2015 (India); Memon 2015
(Pakistan); Newbrander 2014 (Afghanistan); Shaban 2018 (Jordan);
Tesfaye 2019 (Ethiopia):
"We are also ashamed of going to male doctors. How can we tell the
problems we have to a strange or non-family male?" [Newbrander
2014, Afghanistan]
Low
(Continued)
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Table 4. (Continued)
Analytical Theme Review finding Contributing papers Supporting Quote CERQual
Grade
EXPERIENCE OF
CARE
16. Practical support: Women in included studies from a variety of
different HIC contexts and settings expressed the need for practical
support to help with the transition to motherhood. During the immediate
postpartum period women wanted providers to offer support with infant
focused activities like feeding, nappy changing and bathing as well as
offering to care for the newborn while mothers recuperated. Although
family members often stepped in to offer practical support during the
subsequent postnatal stages (at home) some women highlighted a need
for ongoing, infant focused support and those without family assistance
suggested help with domestic responsibilities (shopping, cooking,
cleaning, etc;) might be beneficial.
24 studies (24 HIC): Aune 2012 (Norway); Baker 2005 (UK); Beake
2005 (UK); Cronin 2003 (Ireland); Dahlberg 2016 (Norway); Forster
2008 (Australia), Frei 2011 (Switzerland); Gaboury 2017 (Canada);
Henderson 2016 (USA); Hindley 2005 (UK); Humbert 2009 (USA);
Kurth 2010 (Switzerland); Leirbakk 2018 (Norway) Lewis 2009 (UK);
Munday 2003b (Canada); Noguchi, 2018 (Japan); Persson 2011
(Sweden); Puthussery 2010 (UK); Razurel 2011 (Switzerland); Rouhi,
2019 (Australia); Tully 2017 (USA); Woodward 2016 (Australia); Yeh
2017 (Taiwan); Young 2008 (UK)
"At this [doing the month] stage, physical recovery is essential. I don’t
want to keep my baby with me. I believe if I have enough support from
midwives, I would become a happy and healthy mother [if I was able
to have breaks from caring for my baby]; it also would offer protection
against postpartum depression" [Yeh 2017, Taiwan]
High
"Having no sleep, having no rest and thinking maybe the hospital staff
will give the mother a rest by taking the baby away, for a couple of
hours would be amazing, but there’s none of that, there was no help,
and I actually asked for the help. . . I think it wasthe second night I
just broke down in tears, because I was so exhausted, in so much
agony. . . And I asked for help and they said look, we don’t dothat. I
was a bit surprised that, that help wasn’t available. [Puthussery 2010,
UK].
17. Psychosocial support—For many women in the included studies,
predominantly in HIC settings, the postnatal period elicited a range of
extreme emotions from great joy to exasperation and despair. To cope
with these feelings women often received support from family and friends
and welcomed frequent reassurance from healthcare providers. Some
women expressed a need to discuss their birth with a healthcare provider
(ideally someone who was present at the birth) and sometimes they
highlighted a need to discuss their anxieties, their fear of responsibility or
their perceived insecurities about living up to the ideal of a ’good mother’.
28 studies (25 HIC, 3 LMIC): Aune, 2012 (Norway); Aston, 2018
(Canada); Baker, 2005 (UK); Beake, 2005 (UK); Cronin, 2003
(Ireland); Dahlberg, 2016 (Norway); Forster, 2008 (Australia), Frei,
2011 (Switzerland); Gaboury, 2017 (Canada); George, 2005 (USA);
Henderson, 2016 (USA); Hindley, 2005 (UK); Kirca, 2018 (Turkey)
Kurth, 2016 (Switzerland); Kurth, 2010 (Switzerland); Leirbakk, 2018
(Norway); McCarter, 2016 (USA); Munday, 2003b (Canada);
Newbrander, 2014 (Afghanistan); Noguchi, 2018 (Japan); Persson,
2011 (Sweden); Razurel, 2011 (Switzerland); Ribeiro, 2019 (Brazil);
Rouhi, 2019 (Australia); Tully, 2017 (USA); Woodward, 2016
(Australia); Yeh, 2017 (Taiwan); Young, 2008 (UK)
“When I leave, I feel really good, and every time we leave she says
“You’re doing a great job, mom. Keep it up” And that just makes me
feel so good leaving the office. . .. that you have a doctor who’s really
paying attention to you and your daughter, or your child, and then just
confirms for you when you leave, like “Keep it up. You’re doing
awesome. She’s healthy, she’s happy". So that is a huge deal" [Aston
2018, Canada].
High
“I would appreciate if it was part of the routine to have a little talk after
the birth. . .it doesn’t need to be a long talk or so. . .just as long as you
get to meet the midwife who was there”. [Persson 2011, Sweden].
"And I think there is a preconceived image of the ideal mother. When
I asked friends who gave birth at the same time as me: ‘how is your
daughter? Is she crying a lot?’ They all told me no. They said no, she
never cries. Recently, I asked them again about it, and they then said
that they could not even take a shower! And I said to them: ‘but I
thought that she did not cry?’ And even worse, they had not told me
the truth, and I found this extremely distressing. I do not know, it is all
a facade" [Razurel 2011, Switzerland].
18. Information needs—For many women in the included studies,
largely in HIC contexts, the birth of a newborn triggered a huge array of
informational needs. Some of these needs were met by friends, family,
peers or the internet but women looked to healthcare providers for
specific information about their infant’s feeding, crying or sleeping
behaviours as well as clinical information relating to safety, development
and overall wellbeing. Women also looked to providers for information
about their own needs relating to wound care, the resumption of sex,
contraception and their general wellbeing. For some women the amount
of information provided was too little or given at the ’wrong’ time
(antenatally or immediately after birth) whilst for others the volume of
information given by providers was excessive, inappropriate or
inconsistent.
31 studies (25 HIC, 6 LMIC): Aune, 2012 (Norway); Aston, 2018
(Canada); Baker, 2005 (UK); Beake, 2005 (UK); Cronin, 2003
(Ireland); Dahlberg, 2016 (Norway); Forster, 2008 (Australia), Frei,
2011 (Switzerland); Gaboury, 2017 (Canada); George, 2005 (USA);
Henderson, 2016 (USA); Hindley, 2005 (UK); Khalaf, 2007 (Jordan);
Kirca, 2018 (Turkey); Kurth, 2016 (Switzerland); Miteniece, 2018
(Georgia) McCarter, 2016 (USA); Munday, 2003b (Canada); Noguchi,
2018 (Japan); Persson, 2011 (Sweden); Probandari, 2017 (Indonesia);
Puthussery, 2010 (UK); Razurel, 2011 (Switzerland); Rodin, 2019
(USA); Rouhi, 2019 (Australia); Shaban, 2018 (Jordan): Tully, 2017
(USA); Woodward, 2016 (Australia); Yeh, 2017 (Taiwan); Young,
2008 (UK); Zamawe, 2015 (Malawi)
"No one gave me information after the delivery. No one gave me
information before being discharged" [Kirca 2018, Turkey].
High
"I had my questions ready, what I wanted to know and I got that
information so I was happy. And I had to know what to do if you’ve a
problem, that’s the most important thing". [Frei 2011, Switzerland].
19. Acknowledgement of women—Women in studies from
predominantly HIC settings expressed a desire to be ’seen’ by healthcare
providers. Most women understood and appreciated the focus of care on
their infant’s wellbeing and suppressed or ignored their own need for
attention. They were sometimes surprised and relieved when sensitive
healthcare staff enquired about their wellbeing but, more often than not,
felt disappointed, unsupported and uncared for when their need for
attention or simply to be acknowledged was ignored or overlooked.
20 studies (18 HIC, 2 LMIC): Aune 2012 (Norway); Aston, 2018
(Canada); Baker 2005 (UK); Beake, 2005 (UK); Cronin 2003 (Ireland);
Dahlberg 2016 (Norway); Forster 2008 (Australia), Frei 2011
(Switzerland); Gaboury 2017 (Canada); Hindley 2005 (UK); Khalaf
2007 (Jordan); Kurth, 2016 (Switzerland); McCarter 2016; Mrisho
2009 (Tanzania); (USA); Munday 2003a (Canada); Persson 2011
(Sweden); Puthussery 2010 (UK); Rodin 2019 (USA); Tully 2017
(USA); Woodward 2016 (Australia)
"That someone came to your home to ask you how YOU were doing
was something I appreciated. Everyone tended to ask about the baby,
but suddenly there was someone who wanted to know how WE were
doing after the birth". [Dahlberg 2016, Norway].
High
"It’s kind of disheartening when they come in and ask for (baby) first,
because I’m hurting too” [Gaboury, 2017 Canada].
20. Continuity of carer—Women in studies from a variety of different
HIC settings and contexts highlighted the importance of forming a
trusting relationship with a healthcare provider. For some women this
entailed seeing the same provider for all aspects of maternity care (from
antenatal to postnatal), for others it was important to receive postnatal
care from a provider who was present at the birth, and, for a few, simply
seeing the same person at each postnatal contact was a key component of
quality care. For women who chose to have homebirths the prospect of
seeing the same midwife throughout their maternity journey was an
important factor in their decision-making.
12 studies (11 HIC, 1 LMIC): Alyahya, 2019 (Jordan); Aune 2012
(Norway); Dahlberg 2016 (Norway); Fre, 2011 (Switzerland); Hindley
2005 (UK); Munday 2003b (Canada); Noguchi 2018 (Japan); Persson
2011 (Sweden); Puthussery 2010 (UK); Rodin 2019 (USA); Tully 2017
(USA); Woodward 2016 (Australia)
"If there had been another midwife who came at the home visit, I
would not have had the same experience. The main thing was that it
was exactly her, so that we could continue where we left off. She knew
how I felt during pregnancy. I saw that she was excited about how I
was doing with my baby, so it was more than just a medical check-up,
and that felt very good" [Dahlberg 2016, Norway].
Moderate
‘‘I saw maybe two or three different people over the four or five times
that I went. . . it just wasn’t the same person and I wanted the same
person all the time.” [Woodward 2016, Australia]
(Continued)
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Table 4. (Continued)
Analytical Theme Review finding Contributing papers Supporting Quote CERQual
Grade
21. Disrespect and abuse—Women from studies in a variety of different
countries and contexts reported rude and abusive behaviour by
healthcare providers. As well as a general lack of respect women reported
acts of discrimination and humiliation and verbal and physical abuse
during their PNC encounters. In some contexts, women were scolded or
punished by healthcare providers for giving birth at home.
8 studies (3 HIC, 5 LMIC): Baker, 2005 (UK); Bhattacharyya, 2015
(India); Hindley, 2005 (UK); Humbert, 2009 (USA); Izugbara, 2018
(Nigeria); Kanengoni, 2019 (Zimbabwe); Mrisho, 2009 (Tanzania);
Sialubanje, 2014 (Zambia)
"I actually heard one (midwife) call one mother a crybaby because
she’d had a caesarean and she had stitches. She was puffy and bruised
and sick and because she couldn’t immediately jump up and tend to
the baby whenever she cried they, they called her crybaby because she
would buzz for help because she couldn’t physically get to the child
and do what was needed". [Baker 2005, UK]. "
Moderate
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lack of physical space in some facilities and how this impacted on their sense of personal space
and perception of privacy. Some women felt the opportunity to engage in confidential conver-
sations with family members or healthcare providers was compromised whilst others felt the
shared facilities and tight surroundings in some postnatal wards generated a noisy and disrup-
tive atmosphere. For mothers who already felt exhausted and fatigued from childbirth, the
impact of this environment coupled with their inability to control system-oriented, organiza-
tional routines, led to feelings of frustration and exasperation.
By contrast, for women who gave birth at home, the nurturing nature of familiar surround-
ings as well as their ability to establish personal routines and control access to their home cre-
ated a more relaxing environment. In settings where private facilities were available, they were
generally considered to be of better quality and were utilised by some women with the finan-
cial means to do so. However, in some contexts, the integration between private and public
providers was inadequate and impacted on women’s engagement with postnatal services once
they were discharged from the health facility.
Women’s capacity to engage with postnatal services was influenced by other family mem-
bers and individuals in their social circles. In some contexts, women’s autonomy was inhibited
by patriarchal social structures and decisions relating to engagement with maternity services,
including postnatal care, were largely deferred to husbands. Sometimes, these kinds of deci-
sions were agreed jointly between the woman’s husband and her mother-in-law and some-
times the decision was solely the responsibility of the mother-in-law.
Women expressed that elderly relatives and the broader beliefs and expectations of local
communities influenced their observance of traditional postnatal practices rather than ‘west-
ernised’ approaches to postnatal care, which some may have preferred. In some rural commu-
nities, especially in Africa, the reliance on TBAs to administer specific herbs and medicines in
the postnatal period was integral to a communal belief system, whilst in other settings it was
simply more convenient or financially viable. For other women, especially in Asia, the cultural
practice of ‘doing the month’ involved extended periods of isolation and seclusion and limited
interaction with formal postnatal services. Our findings also indicate that, in these contexts,
some women (and their families) found it difficult to steer a course between the increasing
influence of “Western” approaches to postnatal care and adhering to the traditional practices
advocated by previous generations.
Social norms. Women highlighted a variety of behaviours and understandings about the
health system that affected their willingness to engage with postnatal care providers. For some
women, especially from studies in LMICs, these understandings were based on a perception
that attendance at health facilities offering postnatal care was only necessary if they felt unwell
or if there was a problem with their infant. In many cases, this notion was reinforced by health-
care providers who did not encourage attendance or devalued the services they offered. When
health workers devalued PNC, families also tended to devalue PNC and not see the need to
seek care.
Some women also believed that postnatal services were solely focused on infant wellbeing
and development and, although they valued the services on offer for newborns (clinical assess-
ments and immunizations), they were not aware of, or did not acknowledge, any sources of
care and support for themselves.
For some women, a reluctance to engage with postnatal services was rooted in a lack of
trust in the system. In certain contexts, this was based on a perception that some providers
were corrupt and expected informal payments, gifts, or bribes in return for care. In other set-
tings, women’s trust in the system was undermined by perceived inadequacies in the clinical
or personal skills of the healthcare providers. More infrequently, women complained that con-
fidential information shared with health providers might be compromised or abused and, in
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more extreme cases, women believed that disclosure of mental health issues (like postnatal
depression) might lead to their infant being taken away from them. In a few specific contexts,
women expressed a preference to be seen by female health providers and highlighted safety
concerns when postnatal visits at home were conducted by male health workers.
Experience of care. Based on their experiences of postnatal care, women identified a
range of issues that were of particular importance during their postnatal journey, including the
need for information and support and the desire to be treated with care and respect by familiar
and trusted healthcare providers.
Women from a variety of different settings and contexts highlighted the need for informa-
tion during all phases of postnatal care. Although some of these informational needs were met
by friends, peers, family members and online sources, women looked to healthcare providers
for information about infant nutrition and development as well as tips and advice on infant
crying cues, sleeping patterns, breastfeeding, and safety concerns. Although women tended to
prioritise the needs of their newborns over their own, they also sought personal information
for example on wound care, contraception, and when to resume sexual activity. The timing
and delivery of information was also discussed by many women indicating that information
should be supplied both antenatally and postnatally and given in a clear and consistent format.
For some women, intense emotions of joy and elation coupled with feelings of extreme fatigue
affected their ability to absorb information in the immediate postnatal period, whilst for oth-
ers, the sheer volume of information was difficult to process.
In addition to a need for information, women also identified needs for both practical sup-
port and, especially in high-income countries, for psychosocial support. In a practical sense,
women appreciated the support they received from family members but also valued support
from healthcare providers, particularly in the immediate postpartum period, prior to hospital
discharge, when they were trying to bond with their newborn and/or establish breastfeeding.
Help with specific newborn-oriented tasks like nappy changing and bathing as well as tending
to the newborn whilst the mothers recuperated, showered, or carried out chores, were
highlighted and, in some instances, women felt disappointed when these needs were not
recognised.
In many settings, women also highlighted the need for ongoing practical support once they
returned home and, although this was often facilitated by family members, women also appre-
ciated assistance from healthcare providers during the transition to motherhood. Usually this
was a continuation of the advice received in hospital relating to infant feeding and develop-
ment but, in uncommon circumstances, women received visits from associated agency work-
ers to helped with domestic activities (shopping, cleaning, cooking) and these services were
highly valued.
Many women experienced intense emotional peaks and troughs during the postpartum
period ranging from elation to despair to overwhelming exhaustion. Women, particularly
first-time mothers, discussed their fears, anxieties, and insecurities about becoming a mother
and, for some, the pressure and responsibility of living up to some idealised version of a
mother. Women wanted support from healthcare providers to help them to process and man-
age these difficult emotions and often expressed this in terms of a need for reassurance. In
some contexts, particularly in high-income settings, where much of the published evidence
comes from, women wanted to discuss the birth experience with a midwife who was present or
have access to healthcare providers support if they felt their birth was challenging or traumatic.
In a broader sense, many women felt that their own care needs were overlooked or under-
valued during the postpartum period. Whilst new mothers completely accepted and under-
stood that the focus of postnatal care was on their infant, they nevertheless felt disappointed
when unvoiced pleas for attention or recognition were ignored by healthcare providers.
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Our findings also indicate that women placed great importance on their ability to build a
relationship with care providers and this was particularly apparent in high-income settings.
For some women this involved seeing the same healthcare provider at each postnatal contact,
for others it meant being able to see the same midwife during the postnatal period as they saw
antenatally, and for women who gave birth at home, the prospect of having the same midwife
throughout their maternity journey played a significant role in their decision to opt for a
homebirth. Where women were able to build these relationships, they were more likely to
report ‘a sense of companionship’, ‘trust’ and ‘authenticity’, but in settings where continuity of
healthcare models were not in place, women reported feeling ‘dissatisfied’, ‘like a number’ or
even, ‘like an animal’.
For women in several contexts, interactions with healthcare providers sometimes became
disrespectful and abusive. In high income settings, women indicated that healthcare providers
could be rude or undermining and occasionally discriminatory during postnatal encounters,
whilst in lower-income contexts women reported acts of rudeness, humiliation and, in rare
cases, punishment by health providers.
Discussion
Factors that influence women’s utilization of postnatal care are interlinked, and include access,
quality, and social norms. Five review findings were identified: access and availability; physical
and human resources; external influences; social norms; and experience of care. Many women
recognised the specific challenges of the postnatal period and emphasised the need for emo-
tional and psychosocial support in this time, in addition to clinical care.
Staffing and resources were important to women, although in low-resource settings, more
emphasis was placed on poor physical infrastructure. In low- and middle-income countries,
women further expressed that healthcare providers themselves often devalued postnatal care,
contributing to their lack of utilization and sense of unpreparedness. Many studies from high-
income countries highlighted women’s desire for more psychosocial and emotional support;
yet, women in low income settings may not have been asked as directly about this challenge.
Women also may not believe this is a role of the health system, or may not feel comfortable
stating this as a vulnerability. These findings point to the need to strengthen comprehensive
health care services, which can more fully address the holistic and ongoing needs of women
and their families.
Many of the findings related to experience of care derived from high-income countries.
Because of the number of included studies related to this topic were biased toward high
income countries, this review finding should not be interpreted necessarily as women in low-
and middle-income countries having positive experiences of care; evidence indicates that dis-
respectful practices are common globally [93]. This area is understudied in low- and middle-
income countries and therefore it is difficult to draw robust conclusions. However, it is likely
that women in settings with insufficient resources will more often refer to unhygienic condi-
tions or lack of equipment as a more immediate priority than their experiences, and/or that
they perceive less ability to change the situation than women in settings with more resources.
A recent qualitative evidence review of studies in sub-Saharan Africa affirmed that aspects of
respectful and disrespectful maternity care and women’s previous experiences of health care
influenced their “decisions to access postnatal care services” [94]. The fact that many of the
studies related to experience of care are from high-income settings may reflect the study
authors’ biases and points to the need to study women and families’ experiences more holisti-
cally in low- and middle-income settings.
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When situating this review within the context of other research [29], many similarities
emerge in review findings across various phases of maternity care. From antenatal and intra-
partum through postnatal care, women emphasised the need for information, continuity of
care, adequate resources, and comprehensive and holistic support. Access and cost continue to
be issues for many women, especially in low- and middle-income countries and in rural areas,
but compared with intrapartum care, the incentive to overcome these challenges is further
diminished with the devaluing of postnatal care and perception of low need for healthy
women and their healthy infants. In the postnatal period, women’s access needs include when
and how they can contact healthcare providers and for what purposes. Women greatly value
continuity of care and flexible schedules for obtaining information and assistance. Infrastruc-
ture and health system resources play into both decisions about if and when to seek care, as
well as the experience of care itself. This pattern and commonality across maternity care peri-
ods reflects the fact women may seek care from the same places and thus experience some of
the same facilitators and challenges, but also emphasises women’s perception that maternity
and the postnatal period are a continuum. The factors influencing postnatal care utilization
may be different than other maternal and child health services for a number of reasons: post-
natal may not be seen as important (especially if the woman and newborn are apparently
healthy); during the postnatal care period, maternal and newborn needs may arise at the same
time, adding to complexity of recognition and care seeking; and health care visits may take
place in the home, unlike visits which must take place in a health facility. However, many of
the same factors may be at play, including the recognition of need, the perception of quality,
and the physical barriers such as cost and distance.
The review findings on postnatal care utilization largely conform with previous studies
around what women want during this time period, as well as challenges related to access,
health system quality, and experience of care. Our review builds on previous work in postnatal
care utilization by explicitly including both women and newborns. The strengths of this review
include a rigorous methodology, comprehensive search, very large database, wide search terms
and concepts, and a diverse study team. Our review encompassed a geographically and linguis-
tically diverse search, with a balance of papers from high, middle, and low-income countries,
although the number of available studies from certain regions (e.g. Latin America and the East-
ern Mediterranean) were limited. Despite the design of the search to be global, including a
lack of language restrictions, we identified few papers from Australasia, Middle East, and
South America.
Some potential limitations of the study include the limitations of the included papers them-
selves, especially the different prioritised topics studied in different regions of the world.
Although the objectives of the included papers represented a range of topics, it is possible that
certain areas, as well as certain topics in each region, are understudied. While we acknowledge
that there may be context specific issues, we are bound by the content of the included studies
and recognise that different questions may have been posed to participants in different con-
texts, depending on the nature of the research inquiry and the pre-existing beliefs of the
research team members of those particular studies. Further, the World Bank Country Classifi-
cations are broad and group countries with very different profiles together. Country-specific
terminology (such as the specific words used in a particular setting around health insurance or
a certain cadre of support worker) may not have been captured.
As with other systematic reviews, there is a trade-off between speed and comprehensiveness
and, while our use of sampling could limit our interpretation, our iterative process until reach-
ing saturation increases confidence in our findings [95,96]. New studies have been published
since the end of the search that were not included, however, the comprehensiveness and rigor
of our search and analysis provides confidence in the findings.
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Many papers identified in our search included the term “postnatal care” but in fact referred
only to intrapartum care. It was difficult to disentangle experiences of postnatal care by time
period as this was rarely disaggregated in studies. The differentiation was included in our
extraction form, but some papers reported on when data were collected and others on the
period the respondents were referring to with the latter often encompassing multiple time
points post birth. More research is needed in distinguishing the needs during the immediate
(e.g. pre-discharge from a health facility) and later postnatal periods.
The findings from this study have implications at the individual, family, health system, and
policy levels, and interventions may be needed to address factors at each. Individual empower-
ment of women may be insufficient if her partner, family, or community have significant
influence in healthcare decisions. The desire of women to have increased emotional and psy-
chosocial support may or may not be best served by existing cadres of medical providers.
Future research should explore who the optimal providers might be and what the scope (and
burden) might be for each type of provider, including traditional birth attendants [97] and
non-medical carers. The intervening time from the end of our search to completion of analysis
included the emergence of a global pandemic, which has already had significant impact on
postnatal experiences and care utilization [98,99]. Further areas of research include the impact
of the pandemic on care utilization, increased anxiety and psychosocial support needs [100],
and the role of digital and virtual care technologies [101].
There are clear steps which can be taken to improve the quality, experience, and uptake of
care for women and newborns in the postnatal period. The value of PNC should be promoted
as part of quality improvement, health worker training, and community mobilization. As
much as possible, care should be provided in a continuous and coordinated manner, between
health facilities, clinics, medical offices, communities, and households. At each level there
must be sufficient staffing, resources, and infrastructure to provide high quality of care. Efforts
should be taken to eliminate barriers to cost and transport, including illegal or unethical barri-
ers such as bribes and other out-of-pocket or unanticipated costs for care, and all types of
abuse and denial of care.
Conclusions
Postnatal care must be positioned as a high priority for both the woman and the newborn,
much like antenatal and intrapartum care, and not seen as an optional service, or one only
accessed in cases of emergencies. As a pre-requisite for increased utilization of postnatal care,
quality must be improved [102]. The benefit of postnatal care for the mother and entire family
may increase utilization, especially if services are available to improve emotional and psycho-
social support. The implementation of standards for quality of care and respectful care must
move beyond childbirth to ensure a positive experience of postnatal care for all women and
their newborns.
Supporting information
S1 Appendix. Full search strategy.
(DOCX)
S2 Appendix. A priori framework.
(DOCX)
S1 Checklist. PRISMA 2020 checklist.
(DOCX)
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Acknowledgments
The authors owe a debt of gratitude to Annie Portela at WHO for feedback on the analysis and
manuscript. The authors also acknowledge the methodological inputs from the Cochrane
EPOC group, specifically Simon Lewin, Claire Glenton, and Susan Munabi-Babigamura.
Thank you to the many research assistants who worked on various stages of this review:
Uktarsh Ojha, Clara Tam, Sakshi Jain, Sushama Sreedhara, Younghee Jung, Kate Cho, Lex
Londino, Leonie Sawoh, and Prince Gyebi. Thanks to Kiriko Sasayama for assistance in trans-
lation of an included study.
Author Contributions
Conceptualization: Emma Sacks, E
´tienne V. Langlois, Mercedes Bonet.
Data curation: Emma Sacks, Kenneth Finlayson, Vanessa Brizuela, Nicola Crossland, Daniela
Ziegler, Caroline Sauve
´, E
´tienne V. Langlois, Dena Javadi, Soo Downe, Mercedes Bonet.
Formal analysis: Emma Sacks, Kenneth Finlayson, Vanessa Brizuela, Nicola Crossland, E
´ti-
enne V. Langlois, Dena Javadi, Soo Downe, Mercedes Bonet.
Funding acquisition: Emma Sacks, E
´tienne V. Langlois, Soo Downe, Mercedes Bonet.
Methodology: Emma Sacks, Kenneth Finlayson, Vanessa Brizuela, Nicola Crossland, Daniela
Ziegler, Caroline Sauve
´, E
´tienne V. Langlois, Dena Javadi, Soo Downe, Mercedes Bonet.
Project administration: Emma Sacks, Soo Downe, Mercedes Bonet.
Supervision: Emma Sacks, Soo Downe, Mercedes Bonet.
Validation: Emma Sacks, Kenneth Finlayson, Vanessa Brizuela, Nicola Crossland, E
´tienne V.
Langlois, Dena Javadi, Soo Downe, Mercedes Bonet.
Writing – original draft: Emma Sacks, Kenneth Finlayson.
Writing – review & editing: Emma Sacks, Kenneth Finlayson, Vanessa Brizuela, Nicola Cross-
land, Daniela Ziegler, Caroline Sauve
´, E
´tienne V. Langlois, Dena Javadi, Soo Downe, Mer-
cedes Bonet.
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