ARTICLE IN PRESS

Postpartum care should provide

alternatives to meet parents’ need
for safety, active participation, and
‘bonding’
Gun E.M. Fredriksson,Ulf H˛gberg and Berit M Lundman

Objective: to describe new parents’choice of the type of maternity care they wanted to
receive, the family suite (FS) or an early discharge (ED), and to gain a better understanding
of parents’experiences of different postnatal care alternatives.

Design: a qualitative study using semi-structured interviews.The interviews were analysed

by content analysis.

Setting and participants: eleven couples and one mother, including both f|rst-time and ex-
perienced parents. Six families received care at a FS while the others chose an ED within
24 hours after birth.

Measurements and f|ndings: the postpartum period was experienced as an unpredictable

time for new parents, when the need for safety, participation in decision-making, and
‘bonding’ was felt to be central and decisive to their choice of care.The type of care that the
parents felt best met their needs varied according to the mother’s assessment of her own
and the baby’s health status, the parents’ requirements and experience and the way in
which they, as parents, handled the opportunities and demands of different environments.
However, the opportunities for the parents to choose the form of care they considered best
for their family were limited.

Practical implications: to best fulf|l parents’ wishes and needs in postnatal care alternative
care forms are needed. Also, a way to treat the family as a whole on an individual family
basis must be found and parents of newborn babies should be allowed to choose the form of
care they consider best. & 2003 Elsevier Ltd. All rights reserved.
Gun E.M. Fredriksson
MScN, RNM, Research
Midwife, Department of
Obstetrics & Gynaecology,
Ume(a University Hospital,
SE-901 85 Ume(a, Sweden INTRODUCTION et al. 1997, Barclay & Lupton 1999, Nyberg &
Bernerman Sternhufvud 2000, Lugina et al.
Ulf H˛gberg
MD, PhD, Professor, The period immediately after the birth of a baby 2001). The mother may also feel the need to
Department of Clinical is both a meaningful and an overwhelming time recover, and obtain advice and assistance with phy-
Science, Obstetrics and
Gynaecology, Umea9 for the new mother and father. Becoming a sical and emotional health problems (Ruchala
University, Umea9, Sweden mother is a transition that brings with it & Halstead 1994, Brown & Lumley 1998).
Berit M Lundman contrasting feelings (Sethi 1995, Barclay et al. Since the birth of a baby is a sensitive time for
PhD, RN, Associate 1997) and many first-time mothers are over- the new mother and affects the whole family, the
Professor, Department of
Nursing, Umea9 University, whelmed by the demands of motherhood care environment and opportunity for privacy
Umea9, Sweden (McVeigh 1997). First-time fathers likewise become an essential factor in babybirth and
(Correspondence to: GEMF, experience great change (Henderson & Brouse postnatal care (Burden 1998, Janssen et al. 2000).
E-mail: gun.fredriksson. 1991) and an ‘awakening’ as they become aware Most mothers of newborn babies need to be left
us@vll.se)
of the baby’s enormous needs for care (Hall in peace to take care of themselves, to rest and
Received 4 January 2002 1995). The new mother and father need to be be with the family, and at the same time have
Revised 23 April 2002; given information and practical support while the carers close at hand should the need
10 February 2003
Accepted 2 April 2003 they grow into their new role of parents (Moran for information and support arise. Parents in a

Midwifery (2003) 19, 267^276 & 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/S0266 - 6138(03)00030 -5/midw.2002.0357
 ARTICLE IN PRESS
268 Midwifery
previous study who opted for early discharge
(ED) postpartum described the home setting as
important in providing a feeling of freedom,
peace and privacy, and considered the maternity
ward (MW) unable to provide them with this
(
(Paavilainen & Astedt-Kurki 1997). Several
studies show that among parents choosing an
ED, being in control is important (Hall & Carty
1993, Persson & Dykes 2002). By ‘control’ a
feeling of competence and confidence is meant,
and the ability to decide for oneself and take
responsibility for the new baby. In a study of
pregnant and postnatal women Proctor (1998)
found that ‘control’ involved the feeling of being
confident enough to ask for help or advice when
there is a need for support. Feelings of control
have also been shown among fathers during the
delivery when they take an active part and have a
task (Wikander & Theorell 1997).
For staff providing postnatal care it is
important to understand the concerns and needs
of new parents. The experience of women of care
during the postpartum period has in one work
been described as ‘confirmatory moments of
communion’ (Bondas-Salonen 1998). The new
mother feels she is receiving care when the
midwife takes part in different ways in her (the
mother’s) new situation, when she learns through
the midwife’s teaching and even indirectly, when
she is allowed undisturbed time together with her
baby and family. In a UK study Proctor (1998)
found that midwives underestimated women’s
concerns about issues, such as the importance of
postnatal information, the need for control and
confidence in adjusting to the role of mother, and
involving the woman’s partner in the delivery of
care. Tarkka and Paunonen (1996) found that
the support and help that new mothers received
from the staff at the MW primarily had to do
with concrete help while confirmation and
emotional support were given less frequently.
There was a desire among both primiparae and
multiparae for more individual guidance/post-
natal counselling. Other studies have shown that
the role of the father-to-be is rarely discussed
during the pregnancy (Olsson 2000) and that
there is not sufficient preparation for parenthood
to meet the needs of the man (Donovan 1995).
In Sweden, as in many other Western coun-
tries, the length of hospitalisation following
babybirth has been steadily shortened. Studies
indicate that an ED after childbirth is safe for
carefully selected mothers and babies (Gagnon
et al. 1997, Grullon & Grimes 1997, Odelram
et al. 1998) and does not jeopardise breast
feeding (Kvist et al. 1996). Among parents the
experiences of an ED and early home-coming
appear to be predominantly good, although for
this to be successful a well-organised care system
is required, as well as preparation of the parents
during pregnancy (Winbladh et al. 1994, Darj &
St(alnacke 2000). An alternative to traditional
maternity care or the ED, as described in
Norway, Sweden, and the United States (Parsons
et al. 1999, Lindgren 2000), is what we refer to
here as the ‘family suite (FS)’. This care option
features a more relaxing and home-like environ-
ment located near the hospital in which parents
are offered information, help and support during
the first few days following childbirth.
Setting
Northern Sweden (Umea( ) has had FS hotel
settings since 1994. Family suite hotels are
located next to the hospital area and provide
facilities and care for families where the woman
has had a normal pregnancy and delivery. In
1998 a system for an ED postpartum was started
as an alternative following a normal pregnancy
and delivery. If complications develop during
the pregnancy or delivery, care is provided at the
hospital’s MW.
The maternity ward
The MW is staffed 24 hours per day. Most
women at the MW share a room with another
new mother. At the MW the father and siblings
can visit the mother and the newborn baby
during the day but are not able to stay overnight.
The family suite
At the FS, the family is given a room for the first
3 days postpartum. Midwives work at the FS
during daytime hours but during the study
period FSs were not staffed during night hours.
The FS had 24-hour staff 1994--1997, and again
since 1999. Parents in need of advice or support
at night could contact the staff at the hospital’s
MW by telephone. The FS is closed for a few
weeks in the summer and during this period
families who do not opt for an ED receive care at
the hospital’s MW or in a double room at the
delivery ward.
Early discharge
‘Early discharge’ means discharge from the
hospital/FS for both the mother and the baby
at 6--72 hours following the birth. Both mother
and baby were to be healthy, the pregnancy and
delivery normal, and the baby had to be
examined by a paediatrician before discharge.
Families discharged within 24 hours after deliv-
ery are paid a home visit during the first day at
home. All couples making use of this discharge
option are contacted daily by telephone by a
midwife, and have access to a midwife by
telephone 24 hours a day. At 3--5 days post-
delivery the mother is given a final check-up
and consultation, and the baby is given a
physical examination and phenylketonuria
(PKU) screening.
 ARTICLE IN PRESS
Postpartum care
Care after childbirth has undergone great
changes in the last decades and there are now a
number of different care forms available. The
changes have chiefly been studied from the
perspective of the safety of the mother and baby,
with few studies focusing on the new mother’s
experiences and even fewer on the father’s
perspective. The aim of this study was to describe
the choice of new parents with regard to type of
maternity care, an ED or a FS, and to gain a
better understanding of parents’ experiences in
different care alternatives.
METHODS
The design was a qualitative study using semi-
structured interviews.
Subjects and inclusion criteria
This qualitative study formed part of a larger
study that evaluated the utilisation of health care
services by mothers and newborn babies follow-
ing discharge after childbirth under different
types of maternity care. This larger study
included 773 women and 782 babies. During
the study period 39% of the women studied
received care in the MW, 38 in the FS and 23%
with an ED. The proportion of primiparous and
multiparous mothers at the FS was almost equal,
36 and 39%, respectively, while there was slightly
more than twice as many multiparous mothers
than primiparae, 23 and 10%, respectively, used
the ED alternative (Ellberg et al. 2002).
In this study we focused on families in which
the woman had had a normal pregnancy and
delivery and therefore could choose the type of
maternity care the parents wanted. The partici-
pants were randomly selected from a population
of parents (N = 252) who opted for an ED
(N = 39) or FS (N = 213). All the women gave
birth during the period of March to September
1998, and all parents spoke Swedish. Of the
women originally selected, 11 were excluded
from the study because they did not speak
Swedish. Half of the parents had been moved
to the FS (FS group) within half a day of delivery
and stayed there for about three days. The other
parents had opted for an ED (ED group) within
one day of the birth. As previously mentioned,
all families in the ED group had contact with
maternity home care via home visits, contact by
telephone, and another check-up.
Procedure
About four months after the birth of the baby
the interviewer (GF) contacted the parents by
telephone and gave them information about the
purpose and scope of the interview. The parents
269
were told that their participation would be
voluntary and that they could drop out of the
study at any time. Twelve couples were invited to
participate in the interviews, and one man
declined because he was not able to come to
the interview. The final study group included 23
persons, 11 couples and one mother. The sample
size was judged sufficient to find differences but
not too large to give an unwieldy data size. All
parents were assured that any information
disclosed would be confidential and a time and
place for the interview were set according to their
wishes. Prior to the interview the parents also
received a letter informing them of the study and
interview. The study was approved by the
Research Ethics Committee at Ume(a University,
Ume(a, Sweden (No. 98-167).
Interviews
The interviews were semi-structured and covered
the following areas: information on alternatives
in postnatal care, the decision to opt for an ED/
FS, the woman’s and man’s experiences of ED
after childbirth/their stay at the FS, their
experience of care given in connection with an
ED/at the FS, and the postnatal care the parents
would like to be given if they had more children.
The couples were interviewed together. One
couple chose a separate room at the FS for their
interview and the others were interviewed in their
homes. The interviews were tape-recorded and
transcribed verbatim. Care was taken in the
translation of quotes given here to be faithful to
the original text.
Analysis
Qualitative content analysis was performed
according to Downe-Wambolt (1992). A core
feature of qualitative content analysis is devel-
oping categories on the basis of similarities and
differences at different logical levels (Woods &
Catanzaro 1988).
The analysis, which was not guided by any
particular assumptions, was performed as fol-
lows. The text was first read through several
times, to gain a sense of the whole. Thereafter the
text was divided into content areas to provide a
rough structure. As a next step the text was
divided into meaning units, which were constel-
lations of words or statements that related to the
same central meaning. The meaning units were
condensed and coded. The codes were compared
based on similarities and differences and sorted
into six categories, and seven sub-categories. The
tentative categories were discussed by the mem-
bers of the research team in order to ensure both
accuracy and objectivity.
 ARTICLE IN PRESS
270 Midwifery
FINDINGS
Eight first-time parents participated, five women
and three men. Fifteen parents, seven women
and eight men, had older children. The age of the
parents ranged from 22 to 44 years. The decision
to opt for an ED was taken within one hour of
the birth for all couples except one who took the
final decision 10 hours after childbirth. For the
couples who decided to stay at the FS the
decision to do so was taken within two hours of
the birth.
Regardless of whether the choice was ED or
the FS some common concerns shared among all
the parents were the family, the distribution of
responsibility between the parents and the staff,
the environment of the different care alterna-
tives, and the way in which the family were being
treated by the staff. The type of care in which the
parents felt best met their needs varied according
to the mother’s assessment of her own and the
baby’s health status, as well as the parents’
situation and experience and the manner in
which the parents handled the opportunities
and demands in the different settings. The
findings are shown under six categories, each
with its own sub-category/ies (Fig. 1). Quotes
have been used in reporting some of the findings
to further clarify the parents’ experiences.
Unpredictability
Needs -- and reactions
The postpartum period was experienced as a
time of great unpredictability in the lives of the
new parents. Many questions had arisen during
the pregnancy as the parents thought about
the early period after the birth of their baby.
What needs and reactions would the change in
Category
UNPREDICTABILITY
THE PROS AND CONS
OF DIFFERENT ALTERNATIVES
THE FAMILY
DISTRIBUTION OF RESPONSIBILITY
THE CARE ENVIRONMENT
BEHAVIOUR/ATTITUDE
OF THE STAFF
Fig. 1 Choice of and experiences in post-natal care. Categories and sub-categories.
the family situation bring about? How would
they as parents manage?
All births are different and all children are
different, so you can’t say that this is the way
it’s going to be. But it’ll be the way it is y you
don’t know until afterwards. (mother, ED)
First-time parents in particular described the
uncertainty experienced during the pregnancy
while the parents who had older children thought
more about the siblings’ reactions to the change
in the family. After only a few days some of these
questions had been answered and the parents
started to see some structure emerging in their
new situation.
The pros and cons of different alternatives
Limitations
There was a great deal of variation in the amount
and type of information about postnatal care
that the parents had received during pregnancy.
Particularly, the parents in the ED group
described the information given as insufficient,
which was experienced as a limitation in their
choice of postnatal care. The parents also
described aspects of care that they could not
influence themselves, such as lack of night staff
at the FS and the fact that the FS closed for a
few weeks in the summer. To some of the parents
this meant that none of the alternatives in
postnatal care that was available at the time of
their baby’s birth met with their needs and
wishes:
For me, the thing was that there was no staff
during the night. I thought then that it would
be better to be home with my husband so that
he could help. (mother, ED)
Sub-category
Needs – and reactions
Limitations
Assessing risks and benefits
Privacy as a family –
fellowship outside the family
The parents’ responsibility and
the staff’s responsibility
Opportunities in and problems with
the care environment
Care based on the individual’s
and the family’s needs
 ARTICLE IN PRESS
Postpartum care
Some of the parents said that the written
information they had received about an ED was
an encouragement to return home early after the
birth in the absence of complications. Their
choice did not necessarily reflect whether they
wanted an ED. Their choice of when they
thought it would be suitable to return home
had also been limited:
If someone had said that it was okay, you
don’t have to hurry, then I think I would have
taken the opportunity to rest but then it had
been decided that we’d return home so it was
a little like y I felt like I was being thrown
out. (mother, ED)
Assessing risks and benefits
In the FS group an ED was not a realistic
alternative. The major reason many parents had
for choosing to stay at the FS was the desire to
have a few days’ break before returning to life ‘as
usual’. The first-time parents also expressed a
need for being close to the staff to get support in
their new roles as parents. The parents who
already had children talked about the woman’s
need to rest, which they felt would be better met
at the FS than at home.
Most of the parents in the ED group had
considered ED as an option. Critical to the ED
were the absence of complications and the well-
being of the mother and the baby. Their decision
to be discharged early had not been taken lightly,
however, and particularly the men had had
doubts, especially concerning the mother’s need
to rest and possible medical risks to the mother
and baby. The women’s hesitation had also had
to do with lack of confidence in starting breast
feeding. The main reasons for opting for an ED
were that the family could be together, that they
could determine their new routines themselves
and that it was an advantage to be in a familiar
environment. A supporting circumstance in the
decision was proximity to the hospital and
previous experience of parenthood.
The family
Privacy as a family—fellowship outside the
family
The need for seclusion and the desire not to have
to follow unnecessary routines and be disturbed
were common feelings among all the couples
only a few hours after childbirth:
Childbirth is very intense, so when the baby is
born and they’re done stitching it’s nice to be
able to catch your breath and have a few
hours to yourself, to be alone for a while.
(father, FS)
While the parents in the FS group were largely
satisfied with the privacy they were given in the
271
hours immediately after the birth, parents in the
ED group expressed dissatisfaction with the lack
of opportunity they had been given. Regardless
of the form of postnatal care, the parents felt it
was important that there was the possibility for
the family to be together during the days just
after the childbirth. An ED gave the family the
opportunity to naturally get to know the baby
together:
We became a whole family right away and it
wasn’t really a great big deal for the other
children to meet their little sister right away.
(father, ED)
The parents in the FS group also described the
care form they had chosen as positive in terms of
the family’s opportunity to be together:
It was nice to be able to close the door and be
alone as a family. (mother, FS)
Although most of the men in the FS group
described the opportunity for the family to be
together, the thought remained that the stay at
the FS was chiefly a time for the mother and
baby to get to know one another and for the
mother to rest. The theme that kept emerging
was that the man should be there for the woman
and the baby, but that he should allow them the
closest contact with each other during that initial
time.
The majority of the parents in the ED group
had not felt a great need for social contact
outside the family during the first days at home
and had chosen to have a calm period together:
My parents offered to come but we felt that
it would be nice to be alone for a while.
(mother, ED)
In the FS group the families experienced the
privacy at the FS as very positive. At the same
time they did have an expectation that their stay
would offer a feeling of ‘fellowship’ with other
new parents. The hotel environment, however,
gave them little scope for natural and sponta-
neous social contact and exchange of experi-
ences:
It was like y it was that door and you closed
it. It felt like a loss not to have met other
mothers. (mother, FS)
However, the majority of parents did not feel a
great need for social contact with other parents
during the days at the ‘ward’.
Distribution of responsibility
The parents’ responsibility and the staff’s
responsibility
At the same time that there was a great need for
privacy in the hours following childbirth there
was also a desire for attention from the staff.
 ARTICLE IN PRESS
272 Midwifery
While the parents in the FS group were largely
satisfied with the care received between the
delivery and the move to the ‘hotel ward’, several
parents in the ED group described some lack of
co-ordination and responsibility on the part of
the staff during the hours following the delivery.
Returning home early was a great personal
responsibility for the parents in the ED group,
which the majority experienced very positively.
The parents described a feeling of freedom and
said it felt natural to share the responsibility for
the new baby in the home:
It was wonderful to have them [i.e. the mother
and the baby] home immediately and I believe
that it’s necessary for them to come home for
a man to feel responsibility as a father.
(father, ED)
In the FS group several parents felt that it was
important to be able to take responsibility for the
baby themselves while at the same time having
the security of being close to support and help if
needed:
I wanted to and it felt important to get to feel
that I would be able to manage taking care of
my baby myself y and I knew that I could
push the call button if there was a reason.
(mother, FS)
Other parents expressed a greater need for
regular contact with the staff and said they
received a great deal of help and support during
their days at the FS. The parents also stressed the
importance of being able to decide over your
‘own time’ at the FS. It was important to be
given information about routines.
Although the parents in the ED group chose to
take most of the responsibility upon themselves,
there was still a need for professional support
during the first days after the birth. They needed
someone who was interested in how they were
managing and someone to whom they could turn
regardless of the time of day:
My understanding is that you should try to
have this kind of daily contact even if there
isn’t anything special that’s happening. I don’t
think we had any special questions, just the
feeling of security if we did have a question.
(father, ED)
The home visits, telephone contacts and check-
ups were opportunities for the parents to be
reassured that everything was going well, to get
answers to their questions and to receive
practical assistance. Some of the women in the
ED group during their first days at home
experienced the responsibility in negative terms,
especially if they had problems breast feeding or
felt some uncertainty.
The lack of a night staff at the FS meant a
greater amount of responsibility for the parents
during the night in the FS group, which con-
tributed to some of the nights being worrisome:
We could almost not sleep at all the first night
because she cried so much. We were worried
and couldn’t really calm down. (father, FS)
Both first-time parents and parents who had
older babies described the concrete problems
they had experienced during the nights, when
there was a great need for help and support from
the staff. The problems included problems with
nursing, uncertainty about how to take care of
the baby, and fatigue. Even parents who had
managed well at night and had not experienced
any real problems described worry:
I didn’t feel like I needed any help at night y
but it would have been really difficult if
something had happened. (mother, FS)
The care environment
Opportunities in and problems with the care
environment
The set-up in the delivery ward was described by
the parents in both groups as focusing on the
delivery itself and not suited to postnatal care.
The man’s position after the delivery was not
clear. The parents in both the ED and the FS
group were largely positive about the home
environment and the hotel set-up at the FS. The
terms ‘healthy’ and ‘secure’ were often used to
describe both environments. The familiarity of
the home environment gave the whole family a
feeling of security and the opportunity to
establish their own routines:
I thought it felt fun and nice to come home to
my family, and I did actually sleep best at
home; yes, [it was good] to be able to come
home to normal life right away. (mother, ED)
It was primarily the men who said that they
could better relax in the home environment and
‘be themselves’. They also said that the return
home of the woman and baby was a sign that
everything had gone well. Disadvantages of an
ED were chiefly the woman’s difficulty in making
resting a priority, which several of the multi-
parous mothers reported. The main reasons were
that everything had gone ‘back to business as
usual’ right away:
I had tons of energy and was very busy. Then
everything drained away—it was like some-
body knocked me to the ground. (mother,
ED)
The men in the ED group described difficulty
in giving the woman the rest she needed and at
times when the woman was very tired they
thought that the FS or the MW alternative
would have been the better choice.
 ARTICLE IN PRESS
Postpartum care
The parents in the FS group described the
hotel environment as calm, family-friendly and
fairly luxurious:
An incredibly nice place for me and our oldest
daughter to come to y private room y
doesn’t look like or smell like a hospital. You
can relax (father, FS)
Not having to be in a hospital environment
and being left alone in peace helped give the
feeling that childbirth was healthy and natural:
It felt healthy in some way y and somehow it
is, when you take the step from the hospital to
something else. (mother, FS)
Although the parents regarded the hotel
environment of the FS as suitable for postnatal
care, there was some ambivalence about the
setting. The setting helped give a feeling of
autonomy and control over the situation; how-
ever, at the same time this also gave some parents
a negative feeling of isolation.
Behaviour/attitude of the staff
Care based on the individual’s and the family’s
needs
There was an expectation among both the ED
and the FS group that care, at home and at the
FS, would be oriented toward both parents and
would be based on their individual needs. Most
parents did say that the staff both at the ED and
the FS had treated them on an individual basis
and had given support and help according to the
needs of both parents:
I felt more taken care of when we went home
y because when you’re still at the ward there
are so many mothers and there’s a lot of stress
and there isn’t time for that kind of care.
(mother, ED)
The parents in the FS group said they had felt
great freedom in being able to influence the care
they received:
The staff weren’t pushy, there was no schedule
to follow; we could structure our days more or
less the way we wanted. (father, FS)
DISCUSSION
According to the parents’ description of the
postpartum period, this is a time of many
questions. The parents made a decision based
on the risks and benefits of the different care
alternatives when they made their choice. Their
freedom to choose was, however, limited by a
number of circumstances over which the parents
did not feel they had control. Important factors
in the postpartum period were the opportunity
273
the family had for privacy, and the physical
setting. A third important factor mentioned was
the need parents felt for the staff to take a certain
amount of responsibility during the first days
after childbirth. Regardless of whether care was
provided at home or at the FS the parents
expected to be treated on an individual basis, and
according to their needs.
In summary, then, the postpartum period was
experienced as an unpredictable time for the new
parents, a time during which the need for safety,
for the right to take part in decisions and for
bonding were of central importance and were
decisive to their choice of care. The form of care
that the parents considered to best meet their
needs was dependent on the mother’s assessment
of her own and the baby’s health status, the
parents’ own abilities and experience and the
way in which they handled their responsibilities
and met the new demands in the different
environments.
Although the number of participants in the
study were limited, we feel that saturation was
reached in the interviews. Clinical work with new
parents and conversations with colleagues con-
firm the credibility of the findings. Since we
wanted to avoid conducting interviews with
interpreters, non-Swedish-speaking parents were
excluded. This could be a restriction of repre-
sentativeness as immigrant women who do not
speak Swedish may have different experiences
and expectations of the postnatal care provided
from Swedish-born mothers.
The interview can be seen as a meeting
between people and implies a certain amount of
mutual influence (Hansagi & Allebeck 1994). The
fact that the interviewer in this study is a midwife
and as such is active at the FS and in the ED
programme may have had an impact on the
interviews. However, the time perspective (at the
time of the interviews the families had been at
home for a number of months and contact with
the FS and maternity home care had been
concluded) may have reduced this effect as the
parents were not in any direct position of
dependency when the interview was being held.
Interviewing both parents together has both
advantages and disadvantages. Conducting in-
dividual interviews helps to avoid situations in
which one parent is more talkative, making the
other passive. Our point of departure, however,
was to generate a social interplay that would
bring out the parents’ experiences individually
and as a couple (Grams et al. 1996). All parents
actively participated in the interview. Often the
couples had the same opinion but sometimes
they disagreed with each other.
The unpredictability of the postpartum period
in many ways meant that the parents had to take
‘one day at a time’. At the same time, the parents
felt that it was important to know what to expect
 ARTICLE IN PRESS
274 Midwifery
after the delivery and what care alternatives they
had. Adequate preparation and information
during pregnancy have been shown in earlier
studies to be important factors with regard to
safety and positive parental experiences in ED
(Winbladh et al. 1994, Darj & Sta( lnacke 2000). It
has also been shown that there is a great need for
round-the-clock personal contact in the first days
after ED (Rush & Valaitis 1992). This need for
24-hour support was seen among the parents in
this study regardless of the form of care received,
and can be considered as an expression of the
unpredictability of the postpartum period (Hall
1995, McVeigh 1997, Nyberg & Bernerman
Sternhufvud 2000). The parents in the ED group
were satisfied with the daily contact and the
possibility of reaching the staff by telephone
while the majority of the parents in the FS group
felt that the night staff could not be replaced by
‘telephone support’. When the parents chose the
FS they had a need for—and expectation of—the
staff being available around the clock.
The freedom to choose and the opportunity to
have an effect on care according to the individual
family’s needs and desires were felt to be
important, regardless of whether the interviewees
had received care at home or at the FS. The
maternity care provided must be seen as im-
portant for the whole family, with the dialogue
between the parents and the caregivers being
important. Earlier studies have indicated that
some parents opt for an ED following previous
negative experiences of, or dissatisfaction with,
maternity care (Waldenstrom . & Lindmark 1987,
Arborelius & Lindell 1989). In agreement with
this, the decision to opt for an ED among some
parents in this study was based on dissatisfaction
with the care offered at the hospital or the ‘hotel’
(i.e. the FS). Where no possibility existed for the
family to be together and have access to the staff
around the clock, care at home was the only
remaining alternative. The parents who had
opted for an ED on these grounds said they
did not feel that the decision for an ED had been
a free choice, and they considered free choice to
be essential in deciding to return home early.
Other studies have also indicated this (Arborelius
& Lindell 1989). The parents’ understanding of
freedom of choice in the case of an ED not only
included whether they wished to return home
early but also when was a suitable time for them
to return home. There may be a risk that the
return home is hurried, especially when there is a
scarcity of care and beds in the delivery wards,
MWs and FSs.
It has been reported that being able to share
with the family the new situation following
childbirth with the family is important to new
mothers (Bondas-Salonen 1998) and that new
mothers and fathers need to be united as a family
and involved in the life of the newborn baby
from the very beginning. Among the parents in
the present study the opportunity for the family
to be together was of key importance to the
feeling of security, regardless of the form of care
received. Experienced parents emphasised the
importance of a dignified and secure transition to
the new family situation, and this was also found
(
in previous studies (Paavilainen & Astedt-Kurki
1997). In today’s society, where social ties have
weakened and many new parents lack the active
support of family and friends, men have an
increasingly active role in the care of the baby
and support of the woman (Barclay & Lupton
1999). It therefore seems very important that
both parents are given the opportunity to share
the care and responsibility for their baby and are
also given support in their role as parents early
on. This study clearly shows the significance of
both the psycho-social and physical environ-
ments for the parents’ experiences (cf. Rasmussen
et al. 2000). The familiarity of the home
environment was a decisive factor in their
decision to return home early among the parents
in the ED group, since the familiar home setting
meant security for the whole family. In the FS
group, the parents experienced security in having
a few days’ break at the FS and being freed from
the routines of daily life. Both the FS and the ED
provided the opportunity for the family to be
together and for both the man and the woman to
feel that they were participating in the care of
their newborn baby.
The experience of ‘taking control’ has been
shown to be important to women who opt for an
ED after delivery (Hall & Carty 1993). This
study recorded this desire to feel ‘in control’
among parents in both care forms. Satisfying the
need for ‘bonding’ as a family and the possibility
to control one’s own routines requires meeting
expectations at an individual level but also places
demands on the design of the care environment.
It has been demonstrated that our environment
has a great effect on us as individuals (Rasmus-
sen et al. 2000) and that the way in which our
competence is put to use is affected by the
demands and opportunities of that environment
(Norberg et al. 1992). The importance of the
setting, as well as the feeling of taking part in
decisions and the need for parents to ‘bond’ with
each other and their newborn baby was evident
in both the ED and the FS group. When they left
the hospital environment, either to return home
or to move to a FS, they needed to be able to
relax, ‘be themselves’ and from the beginning feel
a sense of active participation in the care of the
baby. Meeting expectations at an individual level
based on the needs of the whole family requires
knowledge about the needs of new mothers and
fathers in early parenthood.
A common health problem in many women
after childbirth, and one that was also seen in our
 ARTICLE IN PRESS
Postpartum care
study, is fatigue (Brown & Lumley 1998, Greif-
Fishbein & Burggraf 1998). Fatigue can also be
an underlying factor for many other problems in
the first weeks after delivery including physical
complications, emotional changes, and changes
in relationships (Ruchala & Halstead 1994).
Opinions differ, however, as to the best place
for recovery for women after childbirth, at home
or in a hospital (Ruchala & Halstead 1994,
Smith-Hanrahan & Deblois 1995, Carty et al.
1996). The parents in this study had different
feelings about the setting that offered the best
conditions for recovery. This emphasises the
need for different care forms and for counselling
and support to both parents about what they
might expect during the initial period after the
baby is born.
The parents’ need for safety was found to
involve several levels, in as much as they needed
not only medical safety, but also to be united as a
family; they also needed to feel there was a good
distribution of responsibility between themselves
and the staff in the ward. These needs must
therefore be addressed not only in the medical
sense but also in the design of the care setting.
While care after a delivery must be safe from a
medical viewpoint, it must also meet the need for
‘bonding’ and togetherness as a family and for
the right of both parents to participate in
decisions relating to their baby. Studies show
that the support provided by the MW staff to
new mothers is chiefly practical and has little to
do with confirmation and emotional support
(Tarkka & Paunonen 1996). Designing care so
that parents feel medically safe and receive
confirmation and strength in their role as parents
seems to be basic to care after babybirth. This
task becomes an even greater challenge when the
woman and/or baby require hospital care.
Weaknesses were noted by the parents in the
ED group in the care they received between
the time of the baby’s birth and the family’s ED.
The system followed in an early return home has
been shown in previous studies to be crucial to
ensuring safe and secure care (Darj & Sta( lnacke
2000). This indicates the importance of including
all the links in the care chain so that families do
not ‘fall between the cracks’ while waiting for the
next care event to occur. When resources are
scarce there is always a risk that the group of
healthy women and children will be neglected in
favour of those who require more care.
While all the parents’ basic needs were similar,
differences were seen in how and where the
different groups felt their needs were best met.
For some parents care at home was the form that
best met the family’s needs for safety, ‘bonding’
and the right to participate in decisions from the
first days after the birth of the baby. For others,
the FS with its hotel setting worked better to
fulfil these needs. A few parents felt that neither
275
home nor the hotel environment of the FS gave
proper consideration to the family’s needs.
In conclusion, in this study alternative forms
of postnatal care have been shown to be needed
to meet individual expectations and the needs of
the family, and to provide new parents with the
freedom to choose the care form that they feel
can best meet their wishes and needs in the new
situation.
ACKNOWLEDGMENTS
We would like to thank all the parents who took part in
this study by sharing their experiences. The study was
made possible by research and development grants from
the County Council of V.asterbotten, V.asterbotten,
Sweden.
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