February 2007 - Volume 1, Issue 1
THE EFFECT OF DISCHARGE PLANNING ON PHYSICAL STATUS OF IRANIAN MOTHERS IN THE POSTPARTUM PERIOD

	Kashaninia Zahra, MSc; Sajedi Firoozeh, MD Ashraf Khoramirad, MSc, Asghar Dadkhah, PhD University of Welfare & Rehabilitation, Tehran, Iran Department Of Nursing, Medical Sciences University Of Qom, Qom, Iran.
	University of Welfare & Rehabilitation, Koodakyar St. Daneshjoo Blvd., Evin, Tehran, Iran E-mail: kashaninia@uswr.ac.ir

ABSTRACT Objective: To investigate the effect of discharge planning on the physical status of mothers. Participants: One hundred and eighteen women (mean age =21.64 years) participated in this study. They were divided into control and experimental groups randomly. The inclusion criteria were primiparous, normal vaginal delivery, early discharge (during 24 hours), singleton pregnancy, and breastfeeding. The exclusion criteria were premature labour, abnormal neonate, lack of enthusiasm, and lack of accurate address. Interventions: Discharge planning included mother face to face interview, training in hospital and following up by home visits 2-3 days after discharge, for physical examination and training. They were also visited at the end of the first, third, fourth, fifth, and sixth weeks, and followed up by telephone call at the end of the second week. Main outcome measures were demographic questionnaire (24 questions), and physical status check lists (26 questions). Results: There were significant differences between the 2 groups in postpartum complications (Spontaneous perineal wound opening; pv=0.02, abnormal perineum; pv=0.01, abnormal lochia; pv=0.02, abnormal vaginal bleeding pv=0.00, constipation; pv=0.04, anemia; pv=0.00), and in performing post partum exercises (pv=0.00), and using contraception methods(pv=0.00). Conclusions: The findings suggest beneficial effects of performing discharge planning on reducing maternal complications in the postpartum period.

Key Words: Discharge Planning, Mothers, Physical Status, Postpartum Period.

INTRODUCTION

The postpartum period is an exciting, dynamic time in a woman's life, and the professional health care givers play an important role in promoting a smooth transition through this period. They can ensure quality postpartum care through a thorough and consistent approach to medical and psychological conditions. The postpartum period begins one hour after delivery of the placenta and generally lasts six weeks. The World Health Organization (WHO) points out that although there is no official definition, the traditional six-week duration is consistent with the 40-day period commonly observed in many countries.[1,2] Many mothers are exposed to the risk of sudden changes as well as early and late complications during the postpartum period. The complications include infection, depression, mastitis, urinary tract infection (UTI) and hemorrhage.[3]

Adequate protection for mothers and neonates by health professional health care givers could play an effective role in mothers and infants adaptation and prevents physiologic complications following delivery.[3]

Postpartum follow up by health professional health care givers has been recommended by the American National Association of Nurses in the framework of a written and precise discharge program for all mothers who are discharged during the first 48 hours after delivery. WHO also recommends a schedule of postpartum care for mother and child.[4] .The discharge planning program that was conducted was based on several reasons: First, it reduces mother complications in the postpartum period. Second, it causes maternal and neonatal rehospitalization rate reduction during the postpartum period. Third, it also reduces neonatal complications in the postpartum period. This program is begun in hospital and is continued at home. It consists of the following:

1. A criterion to guarantee the discharge of only healthy people.
   
2. Mother's health care during pregnancy period.
   
3. Mother's participation in training classes at the first 24 hours following delivery.
   
4. Telephone calls and at least one visit at home.
   
5. Following the programs of third trimester of pregnancy, hospitalization in postpartum period, advice about warning signs, vaccination times and family planning. [4]

Iranian mothers have been discharged early (during 24 hours after delivery); however, they haven't been followed up by discharge programs. This survey has been conducted to indicate the effect of implementing programs regarding discharge planning that detect and control complications in women, and that might improve quality of life after giving birth.

METHODS

Participants included one hundred and eighteen women (mean of age =21.64y, SD=3.13) by presenting sampling. They were divided into control and experimental groups randomly, according to odd and even days of infants' birth. The inclusion criteria were primiparous, normal vaginal delivery, early discharge (during 24 hours), singleton pregnancy, breastfeeding, resident in Qom city, and Persian language. The exclusion criteria were premature labour, abnormal neonate, lack of enthusiasm and lack of accurate address for follow up.

Procedure: After the study was explained to interested mothers, written informed consent was obtained from volunteers.

Discharge planning included mother face to face interview, training in hospital and following up by home visits. They were visited at home 2-3 days after discharge during which physical examination was performed, and training needs of mothers were determined and recorded. Then, theoretical as well as practical training was conducted. They were also visited at the end of the first, third, fourth, fifth, and sixth weeks, and followed up by telephone call at the end of second week. Routine discharge was carried out for the control group (without any program).

Data was collected by demographic questionnaire - 24 questions (Attachment 1), and physical status check lists - 26 questions (Attachment 2). The demographic and obstetric questions were developed by researchers in Persian language and gathered information by interview about the program. To establish the reliability of questions, a random sub sample of 16 mothers were asked, and coefficent correlation calculated 80% by using a Chronbach and to establish the validity of questions, using a content validity method; evaluation of questionnaire by 10 faculty members of nursing and medicine schools that were experienced in obstetric or neonatal care.

Data were analyzed using descriptive and inferential statistics. Descriptive statistics were used for demographic data as well as to describe the sample. Analytic descriptive statistics including tables of relative frequency distribution and charts were used to compare the two groups. Groups were compared using parametric (Chi-square and T test) and non-parametric (Mann-Whitney test) statistics as appropriate. Differences were considered significant at p= 0.05 (Confidence Interval=95%).

RESULTS
All subjects were married and had normal vaginal delivery. As can be seen in Table 1, the average age of the total participants was 21.64 years (SD=3.13). There were no significant differences between the 2 groups in the following: age, occupation and education of mothers and their husbands, family income, housing condition. Table 2 shows history of mothers before delivery. As can be seen in Table 2, there were no significant differences between the 2 groups in, history of systemic diseases and abortion, being supported, regular referral to prenatal care centers, use of iron and folic acid supplements, episiotomy and unwanted pregnancy rates and any other prenatal problems.

Table 3 presents mothers' physical condition during the postpartum period. Scores on some related items, showed significant decreases in the experimental group as compared to the control group (P-value<0.05). Furthermore there are significant differences in perineal complications, abnormal lochia (foul smelling), abnormal vaginal bleeding, constipation, performing post delivery exercises, anemia and using pregnancy prevention methods at week. [6]

However, in Table 3 no significant differences were observed in some other complications, such as abnormal nipple, nipple fissure, abnormal uterine size, dysuria, frequency and incontinence of urine, chronic fatigue and sleep disorders, and mothers' re-hospitalization rate at sixth week.

DISCUSSION

According to the results of this study, the incidence of anemia was less in the experimental group. There is a good agreement between our results and the results of the study of Mara and et al.[5] They recommend flat administration of iron to all women after spontaneous delivery for prevention of postpartum anemia. Postpartum substitution with iron should last at least three months because of long-lasting sideropenia. Bodnar and et al, showed the high prevalence of postpartum anemia among low-income women and this highlights the importance of anemia screening at 4 to 6 weeks postpartum.[6]

As table 3 shows, mothers are informed better about contraception methods and applied them more by implicating discharge program. Martinson and et al also indicated that without postnatal care, mothers have little information about contraception methods.[3] Blenning and Paladine's study showed that whether breastfeeding or not, postpartum women have unique contraceptive needs.[2] Although evidence suggests delay in resumption of ovulation in breastfeeding women, contraception should be addressed before the traditional six-week postpartum visit to prevent unintended closely spaced pregnancies. Breastfeeding women also may use the lactational amenorrhoea method, alone or with other forms of contraception, for the first six months postpartum. For this method to be effective, the woman must be breastfeeding exclusively on demand, be amenorrhoeic (no vaginal bleeding after eight weeks postpartum), and have an infant younger than six months. The failure rate is less than 2 percent if these criteria are fulfilled.[7, 8, 9]

According to the results of this study foul smelling lochia (and probably puerperal infection), opening of the episiotomy, abnormal perineum and abnormal uterine size were seen less in mothers in the discharge program group. The study results support the results of the Gropp study.10 He indicated that re-hospitalization of mothers due to puerperal infections and mastitis was less in mothers who had been followed up. Blenning and Paladine's study also showed that a structured approach to the postpartum visit ensures that relevant conditions and concerns are discussed and appropriately addressed. They showed common medical complications during this period included persistent postpartum bleeding, endometritis, urinary incontinence, and thyroid disorders.[2]

In this study, the training needs of mothers were determined and recorded individually, and then theoretical as well as practical training was conducted. Mac Arthur's study indicated that common and persistent maternal problems such as backache, perineal pain, urinary and bowel incontinence, sexual problems, hemorrhoids, depression, or exhaustion were not addressed by routine postpartum care programs, so it may be beneficial to base postpartum care on woman's individual needs rather than on routine, but this must be investigated in order to advise proper guidelines and distinguish the roles of various health professionals.[11] Walker and et al showed multidisciplinary, multi-sector committees, institutions and agencies have developed programs for appropriate discharge practice and improved postnatal follow-up.[12]

In general, in this study, a nurse-led discharge program in reducing postpartum complications was effective. The result of Martinson's study emphasized the significant role of nurses in planning and performing a discharge program which is useful for mothers after delivery.[3]

1. First Name
   
2. Last name,
   
3. Mother's age
   
4. Husband's age
   
5. Mother's job
   
6. Husband's job
   
7. Husband's education
   
8. Family income
   
9. Housing condition (tenant,…)
   
10. Systemic diseases (hypertension, diabetes mellitus, infections convulsions, cardiovascular diseases, others)
    
11. Abortion
    
12. To be supported
    
13. Regular refer to prenatal care centers
    
14. Any other prenatal problems
    
15. Unwanted pregnancy
    
16. Episiotomy
    
17. Spontaneous rupture of perineum during delivery
    
18. Use of iron & folic acid supplements
    
19. Neonate's birth weight
    
20. Neonate's sexuality
    
21. Neonate's Apgar score (1 min)
    
22. Neonate's Apgar score (5 min)
    
23. Prenatal mother's weight
    
24. Neonatal nutrition (breast feeding)

Attachment 2. Physical status of mothers' Check List:

1. Nipple fissure
   
2. Abnormal nipple
   
3. Abnormal perineum (redness, pain, infection)
   
4. Perineal wound opening
   
5. Bad odor lochia
   
6. Abnormal vaginal bleeding
   
7. Abnormal uterus size
   
8. Dysuria
   
9. Frequency
   
10. incontinence of urine
    
11. Gastrointestinal disturbances
    
12. Hemorrhoid
    
13. Constipation
    
14. Chronic fatigue & sleep disorders
    
15. Thrombophlebitis
    
16. Performing post delivery exercises
    
17. Using nutrition principles
    
18. Using ferrous and folic acid tablets
    
19. Symptoms of anemia
    
20. Re-hospitalizations in treatment centers
    
21. Mother's weight at 6th week
    
22. Mother's systolic blood pressure at 6th week
    
23. Mother's diastolic blood pressure at 6th week
    
24. Mother's temperature at 6th week
    
25. Using contraceptive methods
    
26. What's the contraceptive methods
    

ACKNOWLEDGEMENTS

We would like to thank the medical staff of Izadi Hospital and also Dr. Anooshirvan Kazemnezhad and Seyede Alaa Hakimi for their cooperation.

REFERENCES

1. World Health Organization, Defining the postpartum period. In: Department of Reproductive Health and Research, World Health Organization. Postpartum care of the mother and newborn: a practical guide. (1998a), Accessed online July 29, 2005, at: http://www.who.int/reproductive-health/publications/msm_98_3/
   
2. Blenning CE, Paladine H. "An approach to the postpartum visit. ", American Family Physician. 2005; 15, 72 (12):2491-6.
   
3. Camacho Carr K. Home care of the new family. In: Martinson IM, Widmer AG, Portillo CJ. Home health care nursing, Philadelphia (PA): WB Saunders; 2002. p. 209-229.
   
4. World Health Organization, Care and service provision in the postpartum period. In: Department of Reproductive Health and Research, World Health Organization. Postpartum care of the mother and newborn: a practical guide. (1998b), Accessed online, July 29, 2005, at: http://www.who.int/reproductive-health/publications/msm_98_3/
   
5. Mara M, Zivny J, Eretova V, Kevasincka J, Kuzel D, Umlaufova A, Marova E. "Changes in markers of anemia and iron metabolism and how they are influenced by antianemic in postpartum period." Acta Obstetric and Gynecology Scan. 2001; 80(2): 142-8.
   
6. Bonader LM, Scanlon KS, Freedman DS, Siega-Riz AM, Cogswell ME. "High prevalence of postpartum anemia among low-income women in the United States. ", Am J Obstetric & Gynecology. 2001; 185(2):438-43.
   
7. Campbell OM, Gray RH. "Characteristics and determinants of postpartum ovarian function in women in the United States.", Am J Obstetric & Gynecology. 1993; 169:55-60.
   
8. Kennedy KI, Visness CM. "Contraceptive efficacy of lactational amenorrhea.", Lancet. 1992; 339:227-30.
   
9. World Health Organization, Task Force on Methods for the Natural Regulation of Fertility. The World Health Organization multinational study of breast-feeding and lactational amenorrhea. III. Pregnancy during breast-feeding. Fertil Steril. 1999; 72:431-40.
   
10. Gropp Phelan J, Taylor JA, Daris RL. "Early newborn hospital discharge after delivery: A comment on cost-effectiveness.", Arch. Pediatrics Adol. Me. 1999; 153.
    
11. Mac Arthur C. "What does postnatal care do for woman's health? ", Lancet. 1999; 30, 353(9150): 343-4.
    
12. Walker CR, Watters N, Nadon C, Graham K, Niday P. "Discharge of mothers and babies from hospital after birth of a healthy full-term infant: developing criteria through a community-wide consensus process." Can J Public Health. 1999; 90(5): 313-5.