The outcomes that matter most

The committee were most interested in whether the timing of the first postnatal contact from a health visitor would improve the identification of safeguarding concerns so this outcome was rated critical. This outcome was important to the committee as they felt that current practice often leads to women having long stretches of time where they do not see a healthcare professional and other times where they see multiple healthcare professionals within a short space of time. With the uneven dispersion of healthcare professional contact, safeguarding concerns may be identified too late. The committee were also interested in the proportion of women breastfeeding exclusively or partially at 6 weeks, 12 weeks and 6 months after birth and this was rated a critical outcome. This outcome was important to the committee as it is common for women to give up breastfeeding in the early postnatal period if problems are encountered. The committee wanted to know whether the timing of the contact with a health visitor would maintain breastfeeding. Finally, the committee were interested in baby mortality within 1 year after birth, which was also a critical outcome.

The committee were also interested in the following important outcomes: emotional attachment between parent and baby when the baby is 12 to 18 months of age, the proportion of women assessed by a healthcare professional as experiencing moderate to severe depression or anxiety at 6 to 8 weeks, 3 months and 6 months after the birth, the proportion of parents satisfied with their postnatal care and the proportion of unplanned attendance for woman or baby to health services or admission to hospital for problems within 8 weeks after the birth.

From the studies identified from the searches, none were selected as relevant from reviewing their title and abstracts. Studies were typically excluded as they were comparing additional postnatal contact compared to standard care, as opposed to comparing the scheduling of the same number of visits. As no evidence was identified, the committee had no data on any of these outcomes to use as a basis for discussions or making recommendations.

The quality of the evidence

No studies were identified which were applicable to this review question.

Benefits and harms

Owing to the lack of evidence, the committee made recommendations based on their knowledge, experience and through informal consensus.

The Department of Health and Social Care’s Healthy Child Programme currently mandates 1 health visitor visit in the antenatal period and 2 health visitor visits in the early postnatal period. The committee agreed that the timing of the postnatal visits could have an impact on various issues, including health outcomes as well as the families’ experience with the postnatal care.

First of all, the committee discussed that the first postnatal contact with the health visitor should be a home visit. This was important as the committee felt that many of the assessments that a health visitor would need to conduct would need to be in person as outlined in the recommendations on assessment and care of the woman and assessment and care of the baby, made on the basis of evidence review F about the essential content of postnatal contacts.

Through discussion about the timing of the first postnatal health visitor contact, the committee agreed it is not uncommon for the time between the final midwife contact and the first postnatal health visitor contact to be within a few days or in some cases a few hours of each other, which can be overwhelming for the family. Having these early postnatal contacts so close together is not beneficial to the woman or baby when both the woman and baby are experiencing rapid changes. Furthermore, it can create a long gap between the first and second postnatal health visitor visit. The committee agreed that having visits more spread out would allow parents to ask questions and have the baby’s progress checked as the changes occur throughout the postnatal period. For these reasons, the committee agreed that the recommendation about the timing of the first postnatal health visitor contact should also address the interlude between midwife and health visitor contacts.

Considering these issues, the committee recommend that the first postnatal contact by a health visitor could usually take place between 7 to 14 days after discharge from midwifery care, which would usually mean 17 and 28 days after birth because the discharge from midwifery care usually happens between 10 to 14 days after birth. Therefore, 17 days would be at least one week after the final midwife contact (if the contact was at 10 days). The committee did not want to recommend 21 days (which would also be 7 days after the last midwife contact if this contact was at 14 days) as they felt the time interval of 17 to 21 days was too restrictive. The committee acknowledged that many health visitors work part-time and not at weekends so a larger window for this first postnatal contact would be most realistic. Therefore, the timing of 7 to 14 days after discharge from midwifery care was agreed.

The committee felt that the benefit of this recommendation included giving hope to families that the health visitor, able to offer help, advice and support would be coming into their home within in a maximum of 2 weeks after the final midwife contact. A further benefit would be avoiding the current situation where women commonly have their last midwife contact and first contact with the health visitor all before 14 days. The next scheduled contact with a healthcare professional would be at 6–8 weeks following the birth. The committee felt this time interval was too long, leaving the families without contact from the healthcare professionals for weeks and sometimes resulting in families contacting the GP or going to the A&E unnecessarily. They agreed that having the postnatal contacts more evenly spread, and not concentrated on the first 2 weeks would be more beneficial to the woman and her baby so that there would not be long gaps and that concerns relating to the baby’s and mother’s health and wellbeing can be assessed and identified throughout the first 8 weeks after birth.

The committee discussed the potential risks or harms associated with the recommendation, if the time between the last midwife contact and the first postnatal health visitor contact would be too long for some families. The committee thought that provided that the woman had a comprehensive routine antenatal home visit by a health visitor (as mandated by the Healthy Child Programme) and that the family had been informed who to contact (and how) with problems or queries, then this interval would not be too long, for a low risk, ‘universal’, family. If, however, there were concerns about the woman or the baby, this would have either already been identified from the antenatal visit or would be passed on from the midwifery team to the health visitor team and it is current practice that an early health visitor contact would be scheduled. For this reason, the committee added a caveat, making a second recommendation on the basis of informal consensus, that in the circumstance that a routine antenatal health visitor home visit has not taken place, an additional early health visitor postnatal home visit could be arranged.

Finally, the committee did consider that a visit around day 28 might decrease the health visitor’s contact with partners as many will have returned to work but on balance they considered the benefits of these recommendations to outweigh the potential harms.

Given the lack of evidence identified for this review, the committee also made a research recommendation that studies should be carried out that would answer this review question on when the first postnatal contact with a health visitor should be made.