Although childbirth is considered to be a normal physiological process, complications may arise in 20% of the cases (Hoque and Klein, 2011; Dippenaar and Da Serra, 2013). Complicated labour and delivery is any process   of   labour   and    delivery    affected    by    any    conditions   or disorders that adversely affect women and their foetal health (Hoque and Klein, 2011). The postpartum period is particularly important for women, as during this period they may develop serious, life-threatening complications. There is evidence  that a large proportion of maternal and neonatal deaths occur during the postpartum period, with postpartum heamorrhage being an important cause; therefore, comprehensive postnatal care of postpartum mothers (PPM) is very essential as failure to do so may result in short or long term postpartum maternal morbidities and mortalities. Although the postnatal period is the most critical period, it is also the most neglected phase for providing quality care for mothers and babies because essential postnatal care and attention to their overall wellbeing may not be available or accessible by the mothers (MOH, 2011; Saleem et al., 2014).

It is estimated that 340 000 maternal deaths occur worldwide each year  in low-income countries and 61% of these maternal deaths occur during the first six weeks after birth, and nearly half of those deaths take place during the first week after delivery (Lohela, 2012; WHO, 2013; Saleem et al., 2014). In the Sub-Saharan Africa including Zambia, many women do not have access to health care during early postnatal period putting them at high risk of illness and death (Warren, 2015; Ngozi et al., 2016).

The Zambia’s safe motherhood guidelines recommend that women receive at least four postnatal checkups, the first within six hours of delivery, the second on the second day following delivery, the third on the sixth day following delivery, and the last within six weeks after delivery (MoH, 2011).

According to the Zambia Demographic Health Survey (2013-2014) (ZDHS), only 63% of women received postnatal care within the critical first two days following delivery broken down as: Forty-eight percent of women received postnatal care within four hours of delivery, 14% received care within 4-23 hours, and 2% were seen 1-2 days following delivery. Twenty-eight percent of women did not receive a postnatal checkup within the recommended time (CSO, 2014). In Lusaka Province, 17% of postpartum mothers did not receive postnatal care within the first critical 2 days after delivery.  The ZDHS also indicates that 70% of postpartum women are cared for by either nurses or midwives. This is contrary to the antenatal care attendance which is at 96% and mothers received care from skilled health personnel (CSO, 2014). This makes postnatal care still to be a problem in terms of accessibility.

The University Teaching Hospital is the biggest referral hospital in Lusaka and the country as a whole with average total deliveries of 1,100 per month out of which more than 30% are complicated (UTH, 2017). Provision of quality care by skilled midwives to women who have complicated deliveries is very cardinal to prevent or reduce short and long term postpartum maternal morbidities and mortalities. The aim of this study was to assess the self reported practices of midwives in the postnatal wards at the UTH on the care of postpartum women who experienced complicated labour and delivery from time of admission to the postnatal wards until their discharge   from   the   hospital.   Improving   health   care performance is an increasing challenge globally; high quality service provision and enhanced patient experience are common elements of health care policy in many countries (Bick et al., 2011). Many studies have concentrated on using clients or postpartum women to rate the care they receive from health care providers including midwives, and most often the rating has been very negative. This has often been without consideration of many factors at hand such as staffing levels, availability of materials and equipment among others (Bick et al., 2011; Morrow et al., 2013).

Furthermore, many studies have focused on the utilisation of postnatal care services and not necessarily on the care midwives deliver to the mothers as seen from the midwives’ perspective. Midwives’ views on the value and role of the postnatal care they provide have received little attention, despite being a core element of the midwifery role since time in memorial (Bick et al., 2011).

There is limited literature that has considered Midwives as respondents in the care they provide to postpartum women, yet nurses and midwives are in an ideal position to report on the quality of care they provide to the clients in the various health settings (McHugh and Stimpfel, 2012) as they are the de facto surveillance system overseeing the patient care experience. The conceptual basis for using nurses as reliable and valid informants about the quality of care in the hospital in which they work is well grounded in organizational sociology (Aiken et al., 2000).

Therefore, nurses and midwives are in a much better position to rate their own care given the background of their work environment and further advocate for change or improvement. It is inherent in any profession to desire to do better and if given an opportunity be able to give a true picture of the situation and give sound recommendations for improvement. This study therefore used nurse-midwives as respondents in the care they rendered to postpartum women with complications of labour and delivery and admitted in postnatal wards

Data were collected using a self administered questionnaire, which contained a 4 point Likert scale questions (Always – 3. Sometimes – 2, Rarely – 1 and Never - 0) and also some closed and open-ended questions to assess midwives’ practices of caring for postpartum women who had complicated labour and delivery. The areas covered were: demographic data, whether care was comprehensive or satisfactory, care during hospitalization which included observations and assessment of the mothers and Information, Communication and Education (IEC) during hospitalization. After the data collection instrument was developed, it was subjected for scrutiny by the supervisors who checked the questions whether they were valid enough to yield the intended responses and advised on the necessary revisions to be made. The questionnaire was then pre-tested at a General Hospital within Lusaka. Midwives working in the postnatal ward completed the questionnaires. Pretesting of the instrument helped establish reliability of the instrument in that after analyzing the questionnaires, areas of  inconsistencies  were  established,  revised  and  retested. The revision of the questionnaires involved removing some repeated questions, and those which were unclear or ambiguous and also rephrasing some questions. The revision of the questionnaire also ensured that questions were clear, concise, appropriate and consistent. The proposal was approved by the Biomedical Research Ethics Committee of the University of Zambia; written permission was granted by the National Research Council under the Ministry of Health and the Senior Medical Superintendents at the UTH and the General Hospital. Privacy, anonymity and confidentiality were maintained and participation in study was purely voluntary.

Collected data were securely kept in a locked cupboard and only accessible to the researcher. Data were entered in a computer and analysed using SPSS version 20 computer statistical package. The demographic variables (age, parity, level of education) were summarized using descriptive summary measures and inferential statistics: expressed as frequencies and percentages/proportions for continuous and categorical variables. Results were presented as frequency distribution tables. Likert scale results were summarised in frequency distribution tables with ‘Always’ scoring the highest mark (3) and ‘Rarely’ the lowest mark (1). A score of ‘Never’ did not attract any mark (0). An average score for each category of care has also been computed on the 4 point likert scale. The following variables assessed the different aspects of care from the time the mothers were admitted to the postnatal wards until their discharge from the hospital: demographic characteristics, whether care was satisfactory and comprehensive, observations and assessment of mothers, self deficit care and IEC.

Demographic characteristic of respondents

There were a total of 51 midwives who participated in the study and all of them 51 (100%) were females 21(41.2%); aged between 30 -39 years and 11(21.6%) were 50 and above years. On level of education, 34(66.7%) had diplomas, 15(29.2%) had certificates and only 2(3.9%) had Bachelors’ degree in nursing. As regards the designation of the respondents, 34(66.7%) were Registered Nurse-Midwives, 14(27.5%) were certified or enrolled midwives and 3(3.9%) were either Nursing officers or ward in charges. Majority of the respondents 29(56.9%) had worked for less than one year in the postnatal wards followed by 18 (35.3%) respondents who had worked between 1- 5 years in the postnatal wards (Table 1).

Whether care of postpartum mothers (PPM) who had complicated labour and delivery was comprehensive and satisfactory

Respondents were asked whether the care they provided to the postpartum mothers who had experienced complicated labour and delivery was comprehensive and satisfactory. Majority of the respondents 40(78.4%) stated that the care they rendered to postpartum mothers with complicated labour and delivery was not comprehensive and satisfactory and only 11(26.6%) felt that the care they provided to the women was comprehensive and satisfactory.

Reasons why midwives thought the care they provided to postpartum mothers who had complicated labour and delivery was not comprehensive and satisfactory

A total of 37(92.5%) midwives out of 40(100%) who had said that the care they provided to the postpartum women with complicated labour and delivery was not comprehensive and not satisfactory gave the following reasons    why     they     thought     the    care    was   not comprehensive and satisfactory. 24(64.9%) out of a total of 37(100) respondents stated that low staffing levels and too much work were the main reasons for care to postpartum mothers not being comprehensive and satisfactory “(Sometimes especially night duty only two nurses get overwhelmed with patients, 50 patients to 2 nurses, can’t observe or do what they need to do on each mother and baby)”; 5(13.5%) stated that inadequate medical and surgical supplies were the main reason and 6(16.2%) stated other reasons such as no motivation for staff “(frustrations, no promotions as to what someone deserves – no appointment for specialized training achieved)”; bad attitude by nurses “(Sometimes even when staffing is good, do not carry out care)”; erratic water supply and inadequate blood for severe cases of anaemia. 2(5.9%) stated that lack of necessary equipment to carry out care as one of the reasons for the care not being comprehensive and not satisfactory as well (Table 2).

Care of postpartum women who had complicated labour and delivery during hospitalization in the postnatal wards

To assess the postpartum care of women with complicated labour and delivery during  hospitalization to postnatal wards, midwives were asked to score themselves on how often they performed caring activities using a 4 point likert Scale which had ‘always -3,  sometimes - 2, rarely - 1 and never  - 0”. Respondents scored themselves as ALWAYS carrying out the caring activities in the following areas: Out of a total of 51 respondents, 47(92.2%) always checked the vital signs, 43(84%) always provided clean environment, 43(84.3%) always administered medicines, 33(64.7%) always assisted with early ambulation,  31(60.8%) always checked for vaginal bleeding, 24(47.1%) always checked the episiotomy/laceration site for healing or signs of infection, 17(33.3%) always examined the abdomen for involution and 15(29.4%) always performed breast examination. The total average score on the 4 point likert scale (always - 3, sometimes – 2, rarely – 1 and never – 0) was 2.5 (Table 3).

Midwives performing self care activities for postpartum mothers who had complicated labour and delivery during time of hospitalization in postnatal wards

In order to assess whether midwives performed nursing care activities for the postpartum women who had complicated labour and delivery while admitted to the postnatal wards, respondents were asked to rate their performance on a 4 point likert scale (always - 3, sometimes – 2, rarely – 1 and never – 0) on how often they performed or assisted the women in the various self care activities while admitted to the postnatal wards. Out of a total of 51 respondents, the following rated themselves as ALWAYS performing or assisting with the caring activities in the following areas:  5(9.8%) always performed or assisted with bed bath, 3(5.9%) always helped women with sitz baths and dressing up and 1(2.0%) always performed or assisted with either oral toilet or grooming for the women. The average total score on the 4 point likert scale (always - 3, sometimes – 2, rarely – 1 and never – 0) was 1.6 points (Table 4).

Information, education and communication (health education) to postpartum mothers who had complicated labour and delivery while admitted in postnatal ward

In order to assess how often respondents delivered IEC to postpartum mothers while admitted in the postnatal wards, respondents were asked to rate themselves on a likert scale (always - 3, sometimes – 2, rarely – 1 and never – 0) on the various IEC (health education) items they gave to the postpartum women who had complicated labour and delivery while admitted to the postnatal wards. Out of a total of 51 (100%) respondents, the following rated themselves as ALWAYS performing the IEC activities to the women as follows: 36(70.6%) always gave IEC on general hygiene, 23(45.1%) on perineal toilet,  19(37.1%) on how to detect excessive bleeding, 32(62.7%) on the importance of early ambulation, 15(29.4%) on involution of the uterus, 5(9.8%) on care of the breasts including management of breast problems, 21(41.25) on importance of exclusive breastfeeding, 16(31.2%) on types of medicines given, relevance and administration, 26(50.9%) on importance of good nutrition, 16(31.4%) on importance of rest and 3(5.9%) on postnatal exercises. The average total score on the 4  point  likert  scale  (always  - 3,  sometimes  – 2, rarely – 1 and never – 0) was 2.2 points (Table 5).

Improving healthcare performance is an increasing challenge globally. High quality service provision and enhanced patient experience are a common element of healthcare policy. Postnatal care especially for women who have had complicated labour and delivery is very critical for prevention of complications in the postpartum period. The aim of this study was to assess the self reported practices of midwives in the postnatal wards on the care of postpartum women who experienced complicated labour and delivery from time of admission to the postnatal wards until their discharge from the hospital.

Midwives assessed their own practices on various aspects of care on the postpartum women who had complicated labour and delivery admitted to the postnatal wards at the University Teaching Hospital – Women and Newborn in Zambia. From the background characteristics, it could be deduced that midwifery is still predominantly female driven as all the respondents were females though qualified at different levels. The scenario may be similar in other parts of the world such as the United Kingdom where sex discrimination was abolished in 1975 which also allowed males to train as midwives; yet the male midwives still make up 0.4% of the entire midwifery population under the National Health System (Jones, 2017).

Facility based postnatal care is very important especially for mothers who have had complicated labour and delivery as mothers are observed and monitored to enhance quick recovery and also to prevent postpartum complications. A number of studies have however found that the care provided to postpartum mothers does not equal to their needs. In a study conducted in Germany, midwives felt that they could not live up to the quality of midwifery care they aspired for, they were disappointed with themselves as they thought that the women were underserved and also disappointed with the care they received. Midwives attributed this situation to them being overwhelmed with work (Lohmann et al., 2018). Similar findings were obtained in a study in which majority of the professional nurses reported that the quality of care for postnatal women had deteriorated meaning that patient care was poor in the public hospitals (Somahela et al., 2015; Pallangyo et al., 2017; Dlamini et al., 2017).

However, some participants in the same study reported that the quality of care had remained the same (Somahela et al., 2015). Other studies also revealed that health care providers felt the same way and they cited similar reasons as in this study for the state of care provided to postpartum women (Raynner, 2010; Mannava et  al.,  2015).  A  study  conducted  in  Victoria, Australia revealed that hospital postnatal care was complex and characterized by multiple barriers which impact on the provision of quality postnatal care (Rayner 2013). Midwives in this study felt in a similar way as in many other studies that the care they provided to postpartum  mothers  who  had   complicated  labour  and delivery admitted to the postnatal wards was unsatisfactory and not comprehensive to meet the needs of the mothers due to a number of factors. This study therefore agrees with other studies that health care providers including midwives are aware of the care they provide to their clients/patients and thus capable to give a clear and unbiased situation of the care they provided to the postpartum women who had complicated labour and delivery. All studies cited low staffing levels as the main reason for their dissatisfaction with the care they provided to the postpartum mothers.

A study on improving inpatient postnatal services, midwives’ views and perspectives of engagement in a quality improvement initiative which also sought to find out the timing when midwives performed observations and examinations on postpartum mothers in postnatal wards revealed low percentages such as, on first contact (7- 13%), at most times (33 -89%) and whenever it was necessary (3 -33%) (Bick et al., 2011).

Midwives in this study scored themselves low in breast examination and postnatal exercises. Another study conducted in Dedza District in Malawi, revealed that only 22% nurse-midwives conducted full postnatal examination on mothers and neonates on discharge and 63% of midwives discharged mothers without checking their vital signs (Chimtembo et al., 2013). The inadequacy in postnatal health care could be attributed to differing priorities and perceptions among health care staff as well as patients themselves and because of this discrepancy, the needs of the postpartum mothers are not  adequately  provided  for  (Fogel, 2017). However, in another study, midwives scored themselves high (85%) on checking the observations on postpartum mothers (Rayner, 2010).

In this study, the average score on always performing observations and examination on mothers was 62% which was not too different from other studies. A study on what prevents quality midwifery care uncovered a number of barriers to the provision of quality care by midwifery personnel.  The barriers were grouped into three broad areas as social, economic and professional with all the three resulting in moral distress and burnout (Filby et al., 2016). Midwives provide the majority of care for women before and during pregnancy, labour and delivery and in the postpartum period but most of the times their views on matters of service delivery may be underplayed.

After enduring a complicated delivery, women may not be in a position to undertake self care activities and it is the duty of the midwives to assist the women depending on the level of independence. Midwives were asked to score themselves on how often they performed caring activities on the postpartum mother who had complicated deliveries in relation to self care deficits (Table 4). Self care nursing activities are those activities which individuals may not be able to perform for themselves because of illness or any other condition but they would be able to do so if they were in good condition (https://en.wikipedia.org/wiki/Self-care_deficit_nursing_theory).

The overall performance was very low as only 5.9% of the  midwives  scored  themselves as ‘Always’ performing the self care activities for the postpartum women who had experienced complicated deliveries. Similar findings have been reported in many studies where health care providers reported not to be able to provide quality of care to postpartum women due to the same reasons cited in this study. However, there are also studies where quality care has been provided by health care providers (Aiken et al., 2000; Mannava, 2015; Lohmann et al., 2018).

Midwives caring for postpartum women with complicated deliveries help in the prevention of complications and enhances quick recovery (Çapik, 2015). A literature view on midwifery in the postpartum period revealed that postpartum mothers who delivered by cesarean section expressed concern that the care and assistance they received was not what they had expected as midwives were uncaring, neglectful and disappointing. Midwives were expected to engage in care of the somatic or physical needs such as relief of pain and the need for mobilization while admitted to postnatal wards (Panagopoulou et al., 2017). A postpartum woman should be cared for as a whole, with all the aspects of care being considered.

Information, Education and Communication (IEC) to postpartum women is a very important component of postnatal care as this ensures continuation of care after discharge from the hospital. Postpartum mothers are educated on various aspects of puerperium and how to care for themselves and their newborn babies to prevent complications that may arise during and after hospi-talization. Midwives were asked to score themselves on how often they educated or advised postpartum mothers on various aspects of postnatal care. Only an average of 37.8% of midwives reported as ‘Always’ giving IEC to postpartum women while admitted in the postnatal wards.

A study conducted in Kenya revealed that the overall adequacy of health information given by health workers to postpartum women was 16% on voiding and pelvic exercises. However, the same study revealed that 92% of health workers gave adequate health information on breast feeding (Kamau, 2014). Another study from Dedza District in Malawi also found that majority of the midwives gave health education to the mothers (Chimtembo et al., 2013).

On the other hand, a literature review on midwifery in the postnatal period indicated that midwives did not give advice to postpartum mothers as the women lacked information and knowledge concerning postpartum care and that there was noticeable lack or inconsistent advice regarding breastfeeding, both in relevance to the importance for the infant or the appropriate technique (Panagopoulou et al., 2017). Women further stated that advice related to their own self care needs and their role in the postpartum period was highly valued.

IEC to postpartum mothers is very important as it empowers mothers to take responsibility of their own health and that of the newborn baby and to prevent postpartum complications which may result in  morbidities and maternal mortalities.

IMPLICATION FOR PRACTICE, POLICY AND NURSING PROGRAMMES

This study has proved that health care providers such as midwives could be engaged to evaluate their own care they provide to the mothers during the postpartum period. As professionals, midwives would give a true reflection of the current situation as they desire to improve on the care they provide to the clients. Midwives’ indication that the care they provide to postpartum mothers who had complicated labour admitted to the postnatal ward was not comprehensive and satisfactory gives an indication that the situation needs to be quickly addressed. There are a number of reasons advanced for the current state of care given to postpartum women which should be taken into consideration such as improvement in staffing levels to cater for the increased workload, increased supply of medical and surgical supplies including provision of necessary equipment. The other reasons such as low motivation, bad attitude, erratic water supply and inadequate blood for severe malaria clients may seem less important, but they are all very cardinal to the provision of quality care to the postpartum mothers. A true turning point comes with self- realization of one’s own inadequacies and a deep desire to do something about it to change the situation. This study has just done that and it is hoped that policy makers will take this opportunity to provide the necessary requisites and challenge the midwives to improve their practice. 

This study has revealed that generally postnatal care to postpartum women who had experienced complicated labour and deliveries is low in a number of areas and therefore needs to be improved. Midwives scored themselves according to the care they provided to the postpartum women admitted to postnatal ward up to the time they were discharged. It is therefore recommended that ward managers should ensure that staffing levels are adequate to match the workload and also provide all the necessary materials and equipment for provision of care. It is also recommended that human resources issues that concern the motivation of midwives such as promotions should be looked at as demotivated workers though given all the requites may still have low output. Situations which make midwives helpless and discouraged such as unavailability of water and blood for anaemic patients should be avoided. The hospital management should always make such provisions to ease up the work of midwives. Ward managers should also make efforts and step up their supervisory skills to ensure that more midwives always undertake the necessary  required  care for the postpartum women who had experienced complicated labour and delivery in order to enhance maternal wellbeing and prevent ill health during the postpartum period.  

Although several studies have proved that nurses and midwives are reliable and valid informants on the care they provide in the hospital, a bias may still exist which may be over rating or under rating themselves. A study in which postpartum women are informants should be undertaken so that comparisons could be made on the care provided to postpartum women who have complicated labour and deliveries.

The authors have not declared any conflict of interests.

We would like to acknowledge the financial support provided by the Norwegian Agency for Development (NORAD) through the NORHED QZA-0848 QZA-MW-13/00032 Grant