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<div class="main-content lit-style" itemscope="itemscope" itemtype="http://schema.org/Book"><div class="meta-content fm-sec"><div class="iconblock whole_rhythm clearfix no_top_margin"><a href="https://www.nice.org.uk" title="National Institute for Health and Care Excellence (NICE)" class="img_link icnblk_img" ref="pagearea=logo&targetsite=external&targetcat=link&targettype=publisher"><img class="source-thumb" src="/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-niceng194er4-lrg.png" alt="Cover of Timing of first postnatal contact by health visitor" /></a><div class="icnblk_cntnt"><h1 id="_NBK571567_"><span itemprop="name">Timing of first postnatal contact by health visitor</span></h1><div class="subtitle">Postnatal care</div><p><b>Evidence review D</b></p><p><i>NICE Guideline, No. 194</i></p><p class="contrib-group"><h4>Authors</h4><span itemprop="author">National Guideline Alliance (UK)</span>.</p><div class="half_rhythm">London: <a href="https://www.nice.org.uk" ref="pagearea=meta&targetsite=external&targetcat=link&targettype=publisher"><span itemprop="publisher">National Institute for Health and Care Excellence (NICE)</span></a>; <span itemprop="datePublished">2021 Apr</span>.<div class="small">ISBN-13: <span itemprop="isbn">978-1-4731-4078-3</span></div></div><div><a href="/books/about/copyright/">Copyright</a> © NICE 2021.</div></div></div></div><div class="body-content whole_rhythm" itemprop="text"><div id="niceng194er4.s1"><h2 id="_niceng194er4_s1_">Timing of first postnatal contact by health visitor</h2><div id="niceng194er4.s1.1"><h3>Review question</h3><p>When should the first postnatal contact by health visitors be made?</p><div id="niceng194er4.s1.1.1"><h4>Introduction</h4><p>The timing of engagement of different healthcare professionals in the postnatal period could have both positive and negative impact on the family during this delicate time period. In current practice, the Healthy Child Programme mandates two postnatal visits within the first 8 weeks from the health visitor team. The aim of this review is to explore what is the appropriate timing for the first postnatal contact by health visitors.</p></div><div id="niceng194er4.s1.1.2"><h4>Summary of the protocol</h4><p>See <a class="figpopup" href="/books/NBK571567/table/niceng194er4.tab1/?report=objectonly" target="object" rid-figpopup="figniceng194er4tab1" rid-ob="figobniceng194er4tab1">Table 1</a> for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.</p><p>For further details, see the review protocol in <a href="#niceng194er4.appa">appendix A</a>.</p></div><div id="niceng194er4.s1.1.3"><h4>Methods and process</h4><p>This evidence review was developed using the methods and process described in <a href="https://www.nice.org.uk/process/pmg20/chapter/introduction-and-overview" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Developing NICE guidelines: the manual 2014</a>. Methods specific to this review question are described in the review protocol in <a href="#niceng194er4.appa">appendix A</a>.</p><p>Declarations of interest were recorded according to NICE’s 2014 conflicts of interest policy until March 2018. From April 2018 until June 2019, declarations of interest were recorded according to NICE’s 2018 conflicts of interest policy. From July 2019 onwards, the declarations of interest were recorded according to NICE’s 2019 <a href="https://www.nice.org.uk/about/who-we-are/policies-and-procedures" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">conflicts of interest policy</a>. Those interests declared before July 2019 were reclassified according to NICE’s 2019 conflicts of interest policy (see Register of Interests).</p></div><div id="niceng194er4.s1.1.4"><h4>Clinical evidence</h4><div id="niceng194er4.s1.1.4.1"><h5>Included studies</h5><p>A systematic review of the literature was conducted but no studies were identified which were applicable to this review question.</p><p>See the literature search strategy in <a href="#niceng194er4.appb">appendix B</a> and study selection flow chart in <a href="#niceng194er4.appc">appendix C</a>.</p></div><div id="niceng194er4.s1.1.4.2"><h5>Excluded studies</h5><p>No studies were identified which were applicable to this review question.</p></div></div><div id="niceng194er4.s1.1.5"><h4>Summary of studies included in the evidence review</h4><p>No studies were identified which were applicable to this review question (and so there are no evidence tables in <a href="#niceng194er4.appd">appendix D</a>). No meta-analysis was undertaken for this review (and so there are no forest plots in <a href="#niceng194er4.appe">appendix E</a>).</p></div><div id="niceng194er4.s1.1.6"><h4>Quality assessment of studies included in the evidence review</h4><p>No studies were identified which were applicable to this review question and so there are no evidence profiles in <a href="#niceng194er4.appf">appendix F</a>.</p></div><div id="niceng194er4.s1.1.7"><h4>Economic evidence</h4><div id="niceng194er4.s1.1.7.1"><h5>Included studies</h5><p>A single economic search was undertaken for all topics included in the scope of this guideline but no economic studies were identified which were applicable to this review question. See the literature search strategy in <a href="#niceng194er4.appb">appendix B</a> and economic study selection flow chart in <a href="#niceng194er4.appg">appendix G</a>.</p></div><div id="niceng194er4.s1.1.7.2"><h5>Excluded studies</h5><p>No economic studies were reviewed at full text and excluded from this review.</p></div></div><div id="niceng194er4.s1.1.8"><h4>Economic model</h4><p>No economic modelling was undertaken for this review because the committee agreed that other topics were higher priorities for economic evaluation.</p></div><div id="niceng194er4.s1.1.9"><h4>Evidence statements</h4><div id="niceng194er4.s1.1.9.1"><h5>Clinical evidence statements</h5><p>No evidence was identified which was applicable to this review question.</p></div><div id="niceng194er4.s1.1.9.2"><h5>Economic evidence statements</h5><p>No economic evidence was identified which was applicable to this review question.</p></div></div><div id="niceng194er4.s1.1.10"><h4>The committee’s discussion of the evidence</h4><div id="niceng194er4.s1.1.10.1"><h5>Interpreting the evidence</h5><div id="niceng194er4.s1.1.10.1.1"><h5>The outcomes that matter most</h5><p>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.</p><p>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.</p><p>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.</p></div><div id="niceng194er4.s1.1.10.1.2"><h5>The quality of the evidence</h5><p>No studies were identified which were applicable to this review question.</p></div><div id="niceng194er4.s1.1.10.1.3"><h5>Benefits and harms</h5><p>Owing to the lack of evidence, the committee made recommendations based on their knowledge, experience and through informal consensus.</p><p>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.</p><p>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.</p><p>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.</p><p>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.</p><p>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.</p><p>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.</p><p>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.</p><p>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.</p></div></div><div id="niceng194er4.s1.1.10.2"><h5>Cost-effectiveness and resource use</h5><p>No economic evidence on the cost-effectiveness of the timing of the first postnatal contact by health visitors was identified. When making the recommendations, the committee agreed that the timing of the first health visitor contact should not affect the total number of health visitor contacts with women and their babies, and therefore the recommendations should have no impact on the total cost of health visitor contacts postnatally. The committee expressed the view that if routine health visitor contacts in the antenatal or postnatal period do not take place, then it is possible that problems developing during the antenatal or postnatal period may not be assessed and addressed, leading to more costly healthcare visits and interventions later in the care pathway, hence they made a recommendation that an additional early health visitor postnatal home visit could be arranged in the exceptional circumstance that a routine antenatal health visitor home visit has not taken place to replace this missed visit.</p></div><div id="niceng194er4.s1.1.10.3"><h5>Other factors the committee took into account</h5><p>In addition to the timing of the visits, the committee acknowledged that communication between midwifery and health visitor teams may be problematic or lacking in current practice. Recommendations about communication between different health care professionals and services were made based on evidence review B.</p><p>The committee also considered the current keep performance indicators (KPIs) for health visiting teams. They recognised that the current KPI target for the first postnatal contact (that is before 14 days) effectively overlaps with the time period when the woman is still under midwifery care, which does not represent the best use of resources. Therefore, the committee aimed to make recommendations that would improve the scheduling of contact for families in the early postnatal period, achieving best value and optimising health outcomes.</p><p>The committee noted during protocol development that certain subgroups of women and health care professionals may require special consideration:
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<ul><li class="half_rhythm"><div>young women (19 years or under)</div></li><li class="half_rhythm"><div>women with physical and cognitive disabilities</div></li><li class="half_rhythm"><div>women with severe mental health illness</div></li><li class="half_rhythm"><div>women who had difficulty accessing postnatal care services.</div></li></ul></p><p>A stratified analysis was therefore predefined in the protocol based on these subgroups. However, considering the lack of evidence, the committee agreed not to make separate recommendations and that the recommendations they did make should apply universally.</p></div></div><div id="niceng194er4.s1.1.11"><h4>References</h4><p>No evidence was identified which was applicable to this review question.</p></div></div></div><div id="appendixesappgroup1"><h2 id="_appendixesappgroup1_">Appendices</h2><div id="niceng194er4.appa"><h3>Appendix A. Review protocol</h3><p id="niceng194er4.appa.et1"><a href="/books/NBK571567/bin/niceng194er4-appa-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Review protocol for review question: When should the first postnatal contact by health visitors be made?</a><span class="small"> (PDF, 230K)</span></p></div><div id="niceng194er4.appb"><h3>Appendix B. Literature search strategies</h3><p id="niceng194er4.appb.et1"><a href="/books/NBK571567/bin/niceng194er4-appb-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Literature search strategies for review question: When should the first postnatal contact by health visitors be made?</a><span class="small"> (PDF, 207K)</span></p></div><div id="niceng194er4.appc"><h3>Appendix C. Clinical evidence study selection</h3><p id="niceng194er4.appc.et1"><a href="/books/NBK571567/bin/niceng194er4-appc-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Study selection for: When should the first postnatal contact by health visitors be made?</a><span class="small"> (PDF, 130K)</span></p></div><div id="niceng194er4.appd"><h3>Appendix D. Clinical evidence tables</h3><div id="niceng194er4.appd.s1"><h4>Evidence tables for review question: When should the first postnatal contact by health visitors be made?</h4><p>No evidence was identified which was applicable to this review question.</p></div></div><div id="niceng194er4.appe"><h3>Appendix E. Forest plots</h3><div id="niceng194er4.appe.s1"><h4>Forest plots for review question: When should the first postnatal contact by health visitors be made?</h4><p>No meta-analysis was conducted for this review question and so there are no forest plots.</p></div></div><div id="niceng194er4.appf"><h3>Appendix F. GRADE tables</h3><div id="niceng194er4.appf.s1"><h4>GRADE tables for review question: When should the first postnatal contact by health visitors be made?</h4><p>No evidence was identified which was applicable to this review question.</p></div></div><div id="niceng194er4.appg"><h3>Appendix G. Economic evidence study selection</h3><p id="niceng194er4.appg.et1"><a href="/books/NBK571567/bin/niceng194er4-appg-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Economic evidence study selection for review question: When should the first postnatal contact by health visitors be made?</a><span class="small"> (PDF, 234K)</span></p></div><div id="niceng194er4.apph"><h3>Appendix H. Economic evidence tables</h3><div id="niceng194er4.apph.s1"><h4>Economic evidence tables for review question: When should the first postnatal contact by health visitors be made?</h4><p>No economic evidence was identified which was applicable to this review question.</p></div></div><div id="niceng194er4.appi"><h3>Appendix I. Economic evidence profiles</h3><div id="niceng194er4.appi.s1"><h4>Economic evidence profiles for review question: When should the first postnatal contact by health visitors be made?</h4><p>No economic evidence was identified which was applicable to this review question.</p></div></div><div id="niceng194er4.appj"><h3>Appendix J. Economic analysis</h3><div id="niceng194er4.appj.s1"><h4>Economic analysis for review question: When should the first postnatal contact by health visitors be made?</h4><p>No economic analysis was conducted for this review question.</p></div></div><div id="niceng194er4.appk"><h3>Appendix K. Excluded studies</h3><div id="niceng194er4.appk.s1"><h4>Excluded studies for review question: When should the first postnatal contact by health visitors be made?</h4><div id="niceng194er4.appk.s1.1"><h5>Clinical studies</h5><p>All studies identified in the search were excluded at the title and abstract stage. Therefore, no clinical evidence was identified for these review questions.</p></div><div id="niceng194er4.appk.s1.2"><h5>Economic studies</h5><p>No economic evidence was identified for this review.</p></div></div></div><div id="niceng194er4.appl"><h3>Appendix L. Research recommendations</h3><p id="niceng194er4.appl.et1"><a href="/books/NBK571567/bin/niceng194er4-appl-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Research recommendations for review question: When should the first postnatal contact by health visitors be made?</a><span class="small"> (PDF, 155K)</span></p></div></div><div class="bk_prnt_sctn"><h2>Tables</h2><div class="whole_rhythm bk_prnt_obj bk_first_prnt_obj"><div id="niceng194er4.tab1" class="table"><h3><span class="label">Table 1</span><span class="title">Summary of the protocol (PICO table)</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK571567/table/niceng194er4.tab1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng194er4.tab1_lrgtbl__"><table><tbody><tr><th id="hd_b_niceng194er4.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population</th><td headers="hd_b_niceng194er4.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"> Women who gave birth to 1, 2 or 3 healthy infants at term.</td></tr><tr><th id="hd_b_niceng194er4.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Intervention</th><td headers="hd_b_niceng194er4.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Early first postnatal home visit by health visitor or family nurse practitioner. An early visit is defined as taking place at an earlier time than the comparator.</td></tr><tr><th id="hd_b_niceng194er4.tab1_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Comparison</th><td headers="hd_b_niceng194er4.tab1_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Late first postnatal home visit by health visitor or family nurse practitioner. A late visit is defined as taking place later than the intervention.</td></tr><tr><th id="hd_b_niceng194er4.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcome</th><td headers="hd_b_niceng194er4.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><b>Critical</b>
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<ul><li class="half_rhythm"><div>Identification of safeguarding concerns</div></li><li class="half_rhythm"><div>Proportion of women breastfeeding (exclusively or partially) at 6 weeks, 12 weeks and 6 months after the birth</div></li><li class="half_rhythm"><div>Infant mortality within 1 year after the birth</div></li></ul>
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<b>Important</b>
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<ul><li class="half_rhythm"><div>Emotional attachment between parent and baby when the baby is 12 to 18 months of age</div></li><li class="half_rhythm"><div>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</div></li><li class="half_rhythm"><div>Proportion of parents satisfied with their postnatal care</div></li><li class="half_rhythm"><div>Proportion of unplanned attendance for woman or baby to health services or admission to hospital for problems within 8 weeks after the birth</div></li></ul></td></tr></tbody></table></div></div></div></div><div><p>Final</p></div><div><p>Evidence review underpinning recommendations 1.1.15 to 1.1.16</p><p>These evidence reviews were developed by the National Guideline Alliance, part of the Royal College of Obstetricians and Gynaecologists</p></div><div><p><b>Disclaimer</b>: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.</p><p>Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.</p><p>NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the <a href="http://wales.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Welsh Government</a>, <a href="http://www.scotland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Scottish Government</a>, and <a href="http://www.northernireland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Northern Ireland Executive</a>. All NICE guidance is subject to regular review and may be updated or withdrawn.</p></div></div></div>
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<div class="post-content"><div><div class="half_rhythm"><a href="/books/about/copyright/">Copyright</a> © NICE 2021.</div><div class="small"><span class="label">Bookshelf ID: NBK571567</span><span class="label">PMID: <a href="https://pubmed.ncbi.nlm.nih.gov/34191453" title="PubMed record of this title" ref="pagearea=meta&targetsite=entrez&targetcat=link&targettype=pubmed">34191453</a></span></div></div></div>
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