INTRODUCTION

In Australia, early obstetric discharge has been definedas a hospital stay of 48 h or less from the time of giving birth.1 In the United States it has been definedas a postpartum stay of one night or less in hospitalfollowing the birth of the baby.2 Clinicians in severalcountries have expressed concerns about the possibleadverse outcomes of early postpartum dischargeincluding infant feeding status at 6 weeks, high preva-lence of feeding problems, low maternal confidenceand postnatal depression.1,3,4

During the past few decades studies have consistentlydemonstrated that maternal behavioural attitudes aresignificantly associated with the health outcomes of themother and her new-born infant.5 The social, culturaland ethnic background of a mother is a significantdeterminant of the health behaviours she will adopt inher new role as a mother when caring for her new-borninfant.6 Among Vietnamese and Chinese women, forexample, the cultural, spiritual and emotional experi-ences associated with giving birth differ significantlyfrom those of women within a Western culture.Compared with Caucasian women, Asian women have

a higher incidence of adverse outcomes such as gesta-tional diabetes, pregnancy-induced hypertension,7 andlow birth weight.8 These adverse outcomes have beenattributed to a range of factors; among these are a lack of knowledge of the usefulness and availability of prenatal care and a significant under-utilization of antenatal care.9 It is possible that a similar lack ofknowledge and familiarity with obstetric inpatient services is prevalent among mothers from a non-English-speaking background (NESB). The post-partum stay in hospital offers a window of opportunityfor providing appropriate education and support forthis group of mothers. In Australia, little informationis available on the profile of NESB mothers who chooseearly discharge, and the factors associated with theirdecision to opt for early discharge.

The socio-economic characteristics of Caucasianmothers who opted for early discharge included an ageof 35 years or older,2,9 low educational attainment,1,10

lack of private insurance,1 and a low level of income.1,11

Thus a low socio-economic status was an importantfactor associated with the choice of early discharge forthese women. Social disadvantage emerged as animportant barrier to accessing health services appropri-ately antenatally as well as the optimal utilization of confinement. Women who left in the first 48 h were more likely to be multiparous,12 suggesting thatfamily obligations were a strong incentive to leave

J. Qual. Clin. Practice (2001) 21, 135–143

Quality of health services and early postpartum discharge:Results from a sample of non-English-speaking women

MAI TRAN,1 MD, MPH, PHD, LIS YOUNG,1* FAFPHM, RCAP, HAI PHUNG,1 MD, MPH,KEN HILLMAN,1,3 MBBS, FRCANAES(ENG), FFICANZCA, KAREN WILLCOCKS,2 RN1The Simpson Centre for Health Service Research and 2Early Childhood and Parenting Services, South Western Sydney Area Health Services, 3Faculty of Medicine, University of New South Wales,Sydney, Australia

Abstract Few studies have explored the knowledge, perceptions and satisfaction of ethnic women in relation toearly obstetric discharge. The aim of this study was to form a profile of Vietnamese mothers who opt for earlypostpartum discharge, and to identify factors associated with those decisions. Focus group discussions, in-depthinterviews and survey questionnaires were utilized to collect information from a sample of 160 mothers. Sixty mothers (38%) opted for early discharge (< 48 h). Factors strongly associated with early discharge were poorcomprehension of English (OR = 6.58, 95% CI = 1.81, 24.02), very low level of education (OR = 3.10, 95% CI = 1.55, 6.20) and first time mother (OR = 2.70, 95% CI = 1.15, 4.27). The in-depth interviews identified further factors driving early discharge, including fear and anxiety when having to approach staff for assistance,and perceptions of disempowerment within culturally unfamiliar hospital surroundings. The findings in this studyought to alert administrators and clinicians to possible negative drivers for the choice of early postpartum discharge by Vietnamese mothers.

Key words: linking quantitative and qualitative methods; maternal and infant outcomes; maternity services; non-English-speaking background; patient perceptions; postpartum discharge.

*Correspondence address: Dr Lis Young, Clinical Co-ordinator, The Simpson Centre for Health Services Research,Liverpool Hospital, Locked Bag 7103, Liverpool BC, NSW1871, Australia (Email: lis.young@swsahs.nsw.gov.au).

hospital early. Other studies demonstrated that earlydischarge was associated with a lower level of obstetricinterventions for the mother.1 Yet other studies havereported positive outcomes associated with early dis-charge such as higher maternal attachment scores,fewer maternal concerns and greater maternal satis-faction with the type of discharge. In view of this vari-ation in profile and outcomes for mothers who opt forearly discharge, it is important to explore the profile ofNESB mothers to ensure maternity services are sociallysensitive to them.

Culture and language impact significantly on migrantwomen’s perceptions of and satisfaction with the carethey receive as maternity inpatients in their new home-land. Satisfaction with specific hospital practices, andthe hospital environment, was found to be low amongThai,13 Filipino, Turkish and Vietnamese women.14

These women left the hospital feeling their expectationsof support and assistance with how to care for theirbaby and themselves during the postpartum period hadnot been met. The lack of appropriate opportunitiesfor rest was a recurrent theme, with women stating thatthe ward staff lacked the capacity to accommodate indi-vidual preferences. This, coupled with a general lackof assistance from the staff, made the opportunities forappropriate rest difficult.14 Language was identified as an important barrier to experiencing high levels of satisfaction with care. Women with low levels of fluency in English reported more problems in com-municating with health professionals resulting in a less positive experience of care.15,16 Women fromVietnamese, Turkish and Filipino backgrounds wereless concerned about the fact that caregivers knew little about their cultural practices, and more concernedabout a rushed environment which they experiencedas unkind and non-supportive.15

Although these problems are well recognised forsome groups of mothers, there is a dearth of data onthe general health needs of Vietnamese immigrants in Australia, particularly in relation to pregnancy and confinement. Vietnamese mothers’ perceptions oftheir physical and emotional well-being during con-finement, and their satisfaction with the hospitalenvironment and the care they receive postpartum,remain virtually unknown within the Australian setting.Similarly the impact these perceptions might have on a Vietnamese mother’s decision to choose early discharge has not been explored.

The present study was undertaken to form a profileof Vietnamese mothers who chose early discharge fromhospital after giving birth, and to identify the factorsassociated with the decision to opt for early discharge.Although previous studies have investigated the socialand obstetric characteristics of mothers on early dis-charge programs, very few, if any, have explored in depth the degree of satisfaction with hospital-basedmaternity care experienced by women from NESB.

METHODS

Setting

The study was conducted between February and June2000. It was a cross-sectional design nested within apopulation framework. It was conducted within theMaternal and Infant Network (MINET), SouthWestern Sydney Area Health Service (SWSAHS). TheMINET project was launched in SWSAHS inNovember 1995. The primary aim of this programmeis to monitor health trends for mothers and theirinfants/children whilst focusing on the excellency of care. MINET targets those mothers and infants/children most at risk of adverse health outcomes.17

SWSAHS is comprised of seven local government areas(LGA) representing a total population of 793 000.SWSAHS has significant pockets of socioeconomic disadvantage. Approximately 34% of the population are born in non-English-speaking countries. A signifi-cant proportion of them come from Vietnam (5.2% ofthe total population in SWSAHS). MINET targets all mothers and their infants/children resident withinSWSAHS (annual birth rate 12 000). Approximately15% of all births in SWSAHS are to women from anAsian background.18

Study population

A convenient sample of one hundred and sixty (160)Vietnamese mothers, aged between 19 and 39 years,who attended an Early Childhood Centre in the suburbof Cabramatta (Fairfield LGA) were recruited. Writteninformed consent was obtained from all the partici-pants. A face-to-face interview was conducted witheach Vietnamese woman by one bilingual project officer (fluent in Vietnamese and English).

Study design

A triangular methodology was adopted based on ashort, structured questionnaire. This tool has beendeveloped and validated in the UK (Appendix I).19,20

It was translated into Vietnamese for the purposes ofthis study, and administered in a face-to-face interview.The interviews were conducted in Vietnamese. Thequestionnaire consists of five parts. It has been devel-oped for use in the evaluation of care across the inter-face between primary and secondary services. Theissues explored across services are the provision ofappropriate and timely information, continuity, andprogress through the system. The mother was engagedby the interviewer within 45–60 min of the mother seeing the early childhood nurse. One interview average 15 min.

In addition to this validated structured tool, asemistructured questionnaire was administered to each

136 M TRAN ET AL .

participant (Appendix II). This instrument was based on work done by Mai Tran with Vietnamesewomen in Australia21 and incorporated questionsderived from a focus group conducted as part of thisstudy. These semistructured questions provided theimportant qualitative component of the study. Theyallowed an in-depth exploration of these Vietnamesemothers’ knowledge, beliefs and attitudes towards preventive care, e.g. antenatal clinics and antenatalclasses. This instrument was also administered inVietnamese.

Standardized measures of maternal characteristicswere included in the data collection to control forknown confounders in relation to mothers’ choice of early postpartum discharge. They included age (< 25 years and > 25 years), marital status (married,unmarried), first time mother (yes, no), self reportedfluency in English (on a scale: very well, well, average,poor, very poor), highest level of education completed,mode of delivery, maternal work profile (working while pregnant and return to work, working while pregnant and not returning to work, did not workbefore or after pregnancy), problems with money orinsurance (yes, no), and attended antenatal education(yes, no).

Statistics

Statistical analyses were used to address two issues:prevalence of early postpartum discharge; and theassociation between a mother’s decision to choose earlydischarge and maternal characteristics. Descriptive statistical techniques such as frequency distributionwere undertaken to ascertain the prevalence of earlypostpartum discharge. Bivariate and multivariate analy-sis was used to analyse the association between thechoosing early discharge and the reasons for doing so.A P-value of less than 0.05 was considered statisticallysignificant. The SPSS package was used for all analyses(Version 9.0; SPSS Inc, Chicago, IL, USA).

RESULTS

Maternal profile

The response rate was 92% (only 15 out of the 175women approached refused to participate). The majorreasons for refusal were the presence of an unsettledor crying baby or lack of time. Refusals were not relatedto age, educational background or duration of settlement in Australia. The age of the women who

HEALTH SERVICES AND EARLY POSTPARTUM DISCHARGE 137

Table 1. Mothers characteristics and preference for early (� 48 h) postpartum discharge

Characteristic Discharge � 48 h Discharge > 48 h Totaln (%) n (%) n = 160

Age (years)� 25 38 (63.3) 39 (39.0) 77> 25 22 (36.7) 61 (61.0) 83

First time motherNo 23 (38.3) 58 (58.0) 81Yes 37 (61.7) 42 (42.0) 79

English comprehensionWell – very well 3 (5.0) 17 (17.0) 20Average 7 (11.7) 40 (40.0) 47Poor – very poor 50 (83.3) 43 (43.0) 93

EducationTertiary/ secondary 32 (53.3) 78 (78.0) 110Primary/none 28 (46.7) 22 (22.0) 50

Marital statusMarried 36 (60.0) 59 (59.0) 95Not married 24 (40.0) 41 (41.0) 65

Mode of deliveryCaesarean sections 3 (05.0) 30 (30.0) 33Healthy vaginal delivery 57 (95.0) 70 (70.0) 127

Maternal work profileWork while pregnant and return 2 (3.3) 16 (16.0) 18Work while pregnant and did not return 20 (33.3) 25 (25.0) 45Did not work before or after pregnancy 38 (63.3) 59 (59.0) 97

Problems with money or insuranceYes 32 (53.3) 36 (36.0) 68No 28 (46.7) 64 (64.0) 92

Attended antenatal classYes 22 (36.7) 28 (28.0) 50No 38 (63.3) 72 (72.0) 110

participated ranged from 20 to 37 years (mean 23years). Seventy-nine women were first time mothers.The majority were residents within the LGA of Fairfieldand Bankstown. The duration of settlement in Australiaranged from 6 to 12 years for these women. Approxi-mately 37% (60/160) of this sample of Vietnamesemothers preferred early postpartum discharge.

Prevalence of early postpartum discharge andmaternal characteristics

The prevalence of early postpartum discharge andmaternal characteristics are shown in Table 1.

A high proportion (83%; 50/60) of the women choos-ing early discharge rated their comprehension ofEnglish as very poor or poor. Approximately two-thirds(38/60) were 25 years or younger, 62% (37/60) werefirst time mothers and 60% (36/60) were married.Forty-seven per cent (28/60) had no education or someprimary schooling only. Almost two-thirds (63%) didnot report working before or after their pregnancy.Slightly more than half (53%) experienced financial difficulty. Almost two-thirds of mothers in this samplereported that they did not attend any antenatal classesduring their pregnancy.

Level of satisfaction with the services in thematernity ward setting

Table 2 reflects the results of the satisfaction of themothers with the services provided during their stay inthe maternity ward. The results in this table representall the mothers who answered yes to the eight questions.More than 40% of the study sample reported that ‘it was difficult to see the one I needed to see’. Whenasked whether ‘it was difficult to get to see the samedoctor or nurse that I wanted to see’, one-third of themothers answered yes.

When asked whether ‘I got enough advice on howto look after myself ’, 69% of mothers felt that they didnot receive adequate support and advice during theirstay in the delivery suite. Approximately one-quarterof mothers thought ‘they were not fully involved in making decisions about their care’. Only 16% of

mothers thought they were given ‘a lot of support’ during their stay in the delivery suite. When askedwhether ‘I always had enough time to discuss my conditions with staff,’ 84% of women reported they had insufficient time to discuss their issues with staffduring their stay in the maternity unit. As many as 75%of this sample answered yes to the question ‘sometimesI felt that I was being discriminated against’.

Responses to the semistructured questionnaire areshown in Table 3. The most common reasons forchoosing early discharge were: reluctance to ask forassistance (35%); anxiety at being separated from family and friends (19%); a perception of the nursingstaff refusing to provide assistance with the care of thebaby when asked (13%); lack of confidence in askingfor culturally appropriate meals (12%); and difficultiesin communicating with the medical and nursing staff(10%).

Associations between maternal characteristics andthe decision to choose early postpartum discharge

The relationship between a decision to choose early postpartum discharge, and the responses to thestructured and semistructured survey questionnaireswas explored (Table 4). Logistic regression revealedthat factors such as self-reported fluency in English(OR = 6.58, 95% CI = 1.81, 24.02), the maternalwork profile (OR = 5.15, 95% CI = 1.12, 23.70), andthe level of education of the mother (OR = 3.10, 95%

138 M TRAN ET AL .

Table 2. Mothers’ satisfaction at delivery suite or maternity ward as determined by survey questionnaire (n = 160)

Question Answered ‘Yes’ (%)

It was difficult to get to see the service of my choice 31I saw the person that I needed to see 43It was difficult to get to see a same GP or nurse that I wanted to see 32I got enough advice on how to look after myself 31I was not adequately involved in making decision about my care 23I was usually given sufficient support 16I usually had enough time to discuss my condition during my consultation 16Sometimes I felt that I was being discriminated against 75

Table 3. Association between preferred reasons for earlydischarge and involvement in decision-making and discussionof care (n = 160)

Reason for early discharge No. mothers (%)

Difficulty in communication 10.0Reluctant to ask for assistance 35.0Anxiety, nervousness 18.8Staff ’s refusal to assist 13.1Unclear instruction 7.5Fear to ask for proper meal 11.9Other 3.8

CI = 1.55, 6.20) were associated with the decision to choose early discharge. The age of the mother (OR = 2.70, 95% CI = 1.39, 5.23), the status as firsttime mother (OR = 2.22, 95% CI = 1.15, 4.27), andexperiencing financial difficulties (OR = 2.03, 95% CI = 1.06, 3.90) were also associated with the decision to choose early discharge.

PERSONAL COMMENTS

Sleep interruptions

The majority of women reported interrupted sleep,especially in the of middle the night. This resulted intiredness and a preference for going home early, so they could have some one look after their baby, e.g.assisting with feeding the baby during the night, andchanging the baby’s nappy. Their mothers or husbandswould help them with these tasks.

T: I could not sleep well during my stay in the maternity

unit, a woman next to my bed pressed the bell to call a

nurse to give her some tablets for her headache, or another

woman on the other side kept going to the toilet.

M: I preferred to go home so my mother could help me to

feed my baby and change her nappy for me. I had had an

operation so it is difficult to do it by myself. Besides, it is

too difficult to ask for help from a nurse during the middle

of the night.

Isolation

The relatively high proportion of Vietnamese women,for whom a lack of fluency in English was an issue,reported feelings of loneliness and a strong sense of isolation after visiting hours.

C: I felt very nervous and very unhappy when my mother

or my husband were not there with me, especially after the

visiting hours were over. I could not sleep because I was

afraid if something happened to me during the middle of

the night, how could I ask for help in English.

Communication problems

The necessity to communicate in English was a majorproblem among this sample of Vietnamese mothers.The ease of communication with their family within

HEALTH SERVICES AND EARLY POSTPARTUM DISCHARGE 139

Table 4. Association between mothers characteristics and preference for early postpartum discharge (n = 160)

Characteristic† Patients discharged ≤ 48 h OR (95% CI)(n/total)

Age (years)> 25 22/83� 25 38/77 2.70 (1.39, 5.23)***

First time MotherNo 23/81Yes 37/79 2.22 (1.15, 4.27)**

English ComprehensionWell – very well 03/20Average 07/47Poor – very poor 50/93 6.58 (1.81, 24.02)***

EducationTertiary/secondary 32/110Primary/none 28/50 3.10 (1.55, 6.20)***

Marital StatusMarried 36/95Not Married 24/65 0.96 (0.50, 1.84)

Mode of deliveryCaesarean section 3/33Healthy vaginal delivery 57/127 4.94 (1.65, 14.77)***

Maternal work profileWork while pregnant and return 2/18Work while pregnant and did not return 20/45Did not work before or after pregnancy 38/97 5.15 (1.12, 23.70)**

Problems with money or insuranceNo 28/92Yes 32/68 2.03 (1.06, 3.90)**

Attended antenatal classYes 22/50No 38/110 1.50 (0.75, 2.94)

†The first group in each category was the reference group; CI, confidence interval. **P < 0.05; ***P < 0.005.

their own culture provided a stark contrast to the unfa-miliar hospital surroundings.

Y: I only wanted to ask for a tablet to relieve my pain and I

did not know how to explain my request to the nurse in my

unit. I tried to endure my pain until my husband come to

visit me, then he could help me to get this medication for

me . . . I did not want to call the interpreter because I

thought it not a big deal.

L: I can not speak English as good as other women so I

was not given enough attention. When I tried to explain to

her some things she kept asking me when is your daughter

going to come and visit you? . I think some midwives tried

their best in maternity ward, but it was still hard for me.

Cultural practice in diet and personal hygiene

The majority of these Vietnamese mothers expresseda strong preference for the their own culturally specificpostnatal customs. This preference translated into adecision to choose early discharge that was heavilyinfluenced by their mothers’ values.

C: My mother wanted me to go home early so she can look

after me the way she thinks is right. She said that after the

children she had, she knows what is good and what is bad

for a young mother.

N: I could not eat hospital foods because I do not like

butter and meat that is not cooked well. I prefer to eat

salty well-cooked fish or pork, but I could not order this

specific dish at the hospital. So I preferred to go home

early to have my meal prepared in a better way.

Relationships with staff

Perceived problems in their relationships with the hospital staff were a major topic of discussion for abouta third of the women in this study. Difficulties withfeeding their baby and in caring for their baby were recurrent problems, especially among first timemothers. These problems were exacerbated by the painand the exhaustion they felt after giving birth. Thesesymptoms accentuated the disappointment they feltwhen they perceived that the nurses were unhelpful orunwilling to listen to their concerns.

Y: I had stitches so I was still feeling pain; it was very

difficult to sit up and change nappies or feed my baby

during the first couple days, although I was expected to

do it. I was very sad and stopped asking for help because

of the unwilling manner of the nurses on my ward; that s

why I wanted to go home early.

M: I was so upset with one nurse in my maternity ward.

She was very nice and happy talking to an Australian

mother who was lying in the bed next to me. As soon as

she turned to me, she raised her voice and scowled her

face when I did not understand what she was talking about.

I asked her to repeat what she had said, then she just

walked away and said, forget it .

C: I ran out of nappies for my baby, I tried to explain to

the nurse that I wanted some extra nappies; but she was

very cranky and said that this hospital is not supposed to

provide extra nappies, it was my responsibility to get

enough nappies for my baby. I was so embarrassed and

too upset to ask for more. I had to wait for my mother to

get some more from the chemist. My baby was wet for a

couple hours while waiting for new nappies. You see, that s

why I would rather go home early.

Hospital environment

The unfamiliar surroundings of the maternity wardwere a major concern for these Vietnamese mothers.

C: I did not like to smell the drugs or sterilised medical

equipment around my bed; this made me feel depressed

and gave me a constant headache.

T: The constant noise around the maternity ward from

nurses speaking to each others, the foot steps, and babies

crying from other beds made me very irritable. This time I

really wanted to be discharged early so I could have more

privacy at home in my own environment and I wear more

comfortable clothes.

D: I preferred to go home early and feel more comfortable

about breast feeding my baby, and not have to do it in front

of other people in the maternity ward. If I did not know

how to care for my baby then I would have my mother or

my older sister to help me.

DISCUSSION

Despite the established recognition of the importanceof the role of culture and social values as driving con-sumer perceptions of health care, few studies haveexplored consumer issues in relation to satisfaction withcare within ethnic populations. This study sought toidentify, through the use of a methodology based onlinking quantitative and qualitative measures, the rolecultural issues may play in the perceptions of and satisfaction with hospital-based maternity services,reported by a sample of Vietnamese women.

The interpretation of the results must incorporate thestrength and weaknesses inherent in the methodologyadopted for this study. The number of subjects in thestudy are relatively high for a qualitative study, thusconclusions can be drawn with greater confidence. Thefocus groups conducted within an informal atmosphereenhanced the confidence of the mothers when express-ing their opinions. One of the real strengths of the studywas the fact that all of the interviews were conductedin Vietnamese by a Vietnamese-Australian femaleresearcher. The suburbs within which most of these

140 M TRAN ET AL .

mothers lived have a large concentration of Vietnameseimmigrants and a relatively homogenous Vietnamesesocial infrastructure. Thus these results may be gener-alisable to other Vietnamese communities in Australia.Despite their strength, the data from this study werecollected retrospectively; therefore, cause-and-effectinferences can not be made. Furthermore, as the dataon marital status, education, parity, duration of settle-ment in Australia and employment were based on recallor self-report, some misclassification or biases may havebeen present in the analysis.

Overall, the satisfaction with the services in thematernity ward setting were low. It is a particular con-cern that a substantial proportion of these womenexpressed a perception of having been discriminatedagainst during their stay in the maternity ward. Thelimited access to the interpreter services was a signifi-cant barrier to obtaining the support these women feltthey needed. As a result the nights in the maternityward became fraught with anxiety and feelings ofintense isolation. A low fluency in English resulted infeelings of disempowerment for these women who werealready vulnerable while learning to negotiate their newrole as mothers. The inability to communicate freelywith staff was particularly distressing for those womenwho were first time mothers, and who had only beenin Australia for a relatively short time. The contrastbetween their specific cultural beliefs and expectationsof care and the maternity ward in an Australian settingwere overwhelming. The anticipated intimacy, associ-ated with becoming a mother for the first time withinan extended Vietnamese family, eluded them alto-gether; the lack of this ‘drove them out of the mater-nity ward’. This disappointment may have led to theperceptions of being ignored by hospital staff, who areoften stretched beyond endurance due to the highthrough put for the hospital-based services of today.The findings in this study where a large proportion of first time mothers opt for early discharge are in contrast to those for Australian-born mothers. So farstudies of Australian-born mothers who choose earlydischarge suggest that they are multiparous,12 whereasAustralian-born first time mothers tend to stay in hospital longer (> 48 h).

The greatest cause for concern within this study is the high proportion of Vietnamese mothers who perceived they were being discriminated against. Theapproach of linking the quantitative and qualitativemethods (in-depth interviews and focus groups) meantthe complexity of these perceptions could be explored.The key importance of the language barrier in isolatingthese women has clearly been identified as a lever forimproving the service delivery for NESB mothers. Thisunderstanding provides useful information that canassist in driving change, e.g. employment policy thatensures an appropriate quota of bilingual hospital staff.In a multicultural society, diversity within service deliv-

ery should become a key objective if equity is to becomea reality for all mothers and infants. One important out-come of this study might be to reduce the perceptionof discrimination by Vietnamese mothers by 50% overthe next 5 years.

The results from this study also highlight feelings of disempowerment as a strong negative incentive tochoosing early discharge. Lack of involvement in making decisions about one’s own care and not havingadequate time for discussions with staff were negativedrivers for a significant proportion of these motherswho chose early postpartum discharge. It is possiblethat such negative incentives might result in negativeoutcomes for these mothers and their infant, both shortand long-term, e.g. low uptake of breast-feeding andreluctance to utilize health promoting services duringinfancy and early childhood. This is borne out by thefact that a significant proportion of the women whochose early discharge had not attended antenatalclasses, a finding that is consistent with the study ofLewis et al.3 The low level of satisfaction with specifichospital practices reported in this study was also identi-fied in other the studies.13,14 The greatest increase inodds of ‘early obstetric discharge’ were associated withinsufficient time for discussion with hospital staff, anda lower levels of education of the mother.1,10

The perceptions by the mothers in this study of thehospital staff ’s unwillingness or inability to accommo-date individual preferences, coupled with a lack of prac-tical assistance, are similar to the findings in the studyof Yelland et al. in 1998.14 Vietnamese mothers who hadnot joined the work force before pregnancy, and whointended to stay at home with their children, were alsomore likely to choose early discharge. Considering thatnegative drivers for the early discharge were identifiedthis might mean missing a window of opportunity forengaging Vietnamese-speaking mothers as they enterinto the challenging role of being a mother within a culture as yet not well understood by them.

There have been no previous studies in the Australiansetting providing an in-depth examination of the pre-dictors of early obstetric discharge among first timeVietnamese mothers. Consistent with previous studiesour results suggested that the most common barrier to accessing and engaging health services for NESBmothers was based on language.15,16,22

Our results for Vietnamese mothers younger than 25years are different to those of Margolis et al., who founda strong association between early postpartum dis-charge and older mothers (> 35 years) for Australian-born mothers.2

Implications for improving quality of maternityservices

This study identified significant un-met needs forVietnamese mothers during their confinement. The key

HEALTH SERVICES AND EARLY POSTPARTUM DISCHARGE 141

barrier was a lack of fluency in the English language.A limited access to interpreters, the absence of bilingual staff on the maternity ward and culturallyunfamiliar surroundings led to a perception of almosttotal isolation for this group of mothers during theirhospital stay. These factors were important drivers of choosing early discharge and low satisfaction withservices.

There are two issues for managers and clinicians if they are to improve the maternity services forVietnamese mothers and their new-born infants. First,bilingual staff must form a quota of every shift on amaternity ward; the evening and night shifts are the priority if resources prevent all shifts from being covered. Second, the biomedical model for maternityservices should be integrated with the health beliefs ofthe diverse cultures represented within the Australianpopulation to ensure appropriateness of services foreveryone. Health promoting activities within the mater-nity services in particular ought to engage the beliefsand attitudes of the mothers and their families acrossall cultural and social backgrounds, if measurableimprovement of the health of mothers and their babiesis to be achieved.

ACKNOWLEDGEMENTS

We would like to acknowledge the strong support fromthe staff at the Cabramatta Well Baby Clinics. In particular, we thank the Vietnamese mothers who visited this clinic and were so open and generoustowards us.

REFERENCES

1 Brown S, Lumley J & Small R. Early obstetric discharge: doesit make a difference to health outcomes? Paediatr. Perinat.Epidemiol. 1997; 12: 49–71.

2 Margolis LH & Kotelchuck M, Chang HY. Factors associated with early maternal postpartum discharge from the hospital. Arch. Pediatr. Adolesc. Med. 1997; 151:446–72.

3 Braveman P, Egerter S, Pearl M, March K & Miller C.Problems associated with early discharge of newborns andmothers: A critical review of the literature. Pediatrics 1995;96: 716–26.

4 Small R., Lumley J & Brown S. To stay or not to stay: Arefears about shorter postnatal hospital stay justified? Midwifery1992; 8: 170–77.

5 Whiteford LM & Szelag BJ. Access and utility as reflectionsof cultural constructions of pregnancy. Prim. Care Update Ob.Gyns. 2000; 7: 98–104.

6 Rossiter JC. Attitudes of Vietnamese women to baby feeding practices before and after immigration to Sydney.Midwifery 1992; 8: 103–12.

7 South Western Sydney Area Health Services (SWSAHS).Diabetes Health in South Western Sydney: Strategic Plan forImproving Health, 1997–2002. SWSAHS, Liverpool, 1996.

8 Fuentes-Afflick E & Hessol NA. Impact of Asian ethnicityand national origin on infant birth weight. Am. J. Epidemiol.1997; 15: 148–55.

9 Rossiter JC. Maternal-infant health beliefs and infants feeding practices: The perception and experience of immi-grant Vietnamese women in Sydney. Contemp. Nurs. 1992;1: 75–6, 79–82.

10 Kvist LJ, Persson E & Lingman GK. A comparative studyof breastfeeding after traditional postnatal hospital care andearly discharge. Midwifery 1996; 12: 85–92.

11 Norr KF, Nacion KW & Abramson R. Early discharge withhome follow-up. Impacts on low-income mothers andinfants. J. Obstet. Gynecol. Neonatal Nurs. 1989; 18: 133–41.

12 Brown S & Lumley J. Reasons to stay, reasons to go. Resultsof an Australian population-based survey. Birth 1997; 24:148–58.

13 Rice PL, Naksook C & Watson LE. The experiences of post-partum hospital stay and returning home among Thaimothers in Australia. Midwifery 1999; 15: 45–7.

14 Yelland J, Small R, Lumley J, Rice PL, Contronei V &Warren R. Support, sensitivity, satisfaction. Filipino, Turkishand Vietnamese women’s experiences of postnatal hospitalstay. Midwifery 1998; 14: 144–54.

15 Small R, Rice PL, Yelland J & Lumley J. Mothers in a newcountry. The role of culture and communication inVietnamese, Turkish and Filipino women experiences of giving birth in Australia. Women Health 1999; 28: 77–101.

16 Woollett A, Dosanjh N, Nicolson P, Marshall H,Djhanbakheh O, Hadlow J. The ideas and experiences ofpregnancy and childbirth of Asian and Non-Asian womenin east London. Br. J. Med. Psychol. 1995; 68: 65–84.

17 Phung H, Young L, Greenfield D, Bauman A & Hillman K.A framework for monitoring maternal and infant health status. Aust. Health Rev. 2001; 24: 105–15.

18 Epidemiology Unit, Division of Public Health, SouthWestern Sydney Area Health Service (SWSAHS). Health inSouth Western Sydney: An Epidemiological Profile 2000.SWSAHS, Liverpool, 2000.

19 Baker R, Preston C, Cheater F & Hearnshaw H. Measuringpatients’ attitudes to care across the primary/secondary interface. The development of the patient career diary. Qual. Health Care 1999; 8: 154–60.

20 Preston C, Cheater F, Baker R & Hearnshaw H. Left inlimbo. Patients’ views on care across the primary/secondaryinterface. Qual. Health Care 1999; 8: 16–21.

21 Tran M. Associated risk factors in developing cervical cancer among Vietnamese women living in New SouthWales. Unpublished PhD Thesis. Medical School, Queens-land University, Queensland, Australia, 2001.

22 Kinzie JD, Manson SM, Vinh DT, Tolan NT, Anh B & Pho TN. Development and validation of a Vietnamese language depression scale. Am. J. Psychiatry 1982; 139:1276–81.

142 M TRAN ET AL .

HEALTH SERVICES AND EARLY POSTPARTUM DISCHARGE 143

Agree Strongly agree Disagree Strongly disagreeNeutral

1. It was difficult to get to see the service of mychoice

2. I saw the person that I needed to see3. It was difficult to get to see a GP or nurse that

I wanted to see

4. I got enough advice on how to look after myself5. I was not adequately involved in making

decision about my care6. I was usually given sufficient support7. I usually had enough time to discuss my con-

dition during my consultation8. Sometimes I felt that I was being discriminated

against.

APPENDIX I

Short survey questionnaire

1. Are you first time mother?2. What is your highest qualification?3. Are you married?4. Did you attend antenatal class?5. How did you see the importance of regularly

attending antenatal clinics?6. How long did you wait at the antenatal clinic?7. Did you understand the procedure and the

results of your tests?8. Were you given enough information about self-

care during pregnancy?9. Did you leave the clinic with unanswered

questions?

Maternity unit and postnatal care

1. How long did you stay in maternity unit?2. Why did you prefer to go home early?3. Did you receive further assistance after being

discharged from the hospital?4. Were you given enough information about self-

care after birth?

5. Did you have any difficulty in communicationwith hospital staff?

6. Were you happy with the assistance of staff gaveyou in breast-feeding and baby care?

7. Why did you stop breast-feeding your baby?8. Were you given guidance or assistance how to

care for your baby and yourself?

Early childhood services

1. How long did you wait for to make yourappointment?

2. Were you given enough information about self-care after birth?

3. Did you have any difficulty in communicationwith the early childhood nurse?

4. Were you happy with the assistance of staff gaveyou in breast-feeding and baby care?

5. Did you leave the clinic with unanswered questions?

6. Is it worthy to have your baby regularly checked-up?

APPENDIX II

In-depth interview

Antenatal care