Mothers' perspectives on the quality of postpartum

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International Journal for Quality in Health Care 2002; Volume 14, Number 5: 393–402

Mothers’ perspectives on the quality of postpartum care in Central Shanghai, China O. A. LOMORO1, J. E. EHIRI2, X. QIAN3 AND S. L. TANG4 1

Department of Infectious and Tropical Diseases, Disease Control and Vector Biology Unit, London School of Hygiene and Tropical Medicine, London, 4Liverpool School of Tropical Medicine, Liverpool, UK, 2Department of Epidemiology and International Health, School of Public Health, University of Alabama at Birmingham, AL, USA, 3Department of Maternal and Child Health, School of Public Health, Medical Center of Fudan University (Formerly Shanghai Medical University), Shanghai, People’s Republic of China

Abstract Objectives. To investigate mothers’ perspectives on the quality of postpartum care services in central Shanghai, China. Design. Semi-structured interviews. Setting. Two maternal and child health posts in two subdistricts in LW District, Central Shanghai, China. Study participants. Fifty postpartum mothers who attended the maternal and child health posts in the two subdistricts in LW District, Central Shanghai, China. Main outcome measures. Mothers’ perceived quality and adequacy of postpartum services. Results. A majority of the mothers (90%; n=45) were primiparas (first time mothers). Half did not consider the postpartum services to be of high quality. They defined high quality as ‘full satisfaction of the mother and the child’. Their perception of quality was influenced by their concern about child care, an area in which they expressed the need for further improvement. Conclusion. Mothers indicated that to improve quality of services further, greater emphasis should be placed on: (1) health education on childcare; (2) more time allocation for discussion with health workers during their postpartum home visits so their questions and concerns could be addressed effectively; (3) access to health workers in times of need rather than during officially prescribed home visits; and (4) provision of continuous training for maternal and child health workers with respect to childcare. The findings will be relevant to health workers and policy makers involved in planning and implementation of maternal and child health services in similar urban settings in developing countries. Keywords: antenatal health, China, evaluation, maternal health, patient satisfaction, postpartum care, quality of care

Health services provided to mothers after delivery constitute an essential component of the package of maternal and child health (MCH) services in any population [1,2]. A woman’s body undergoes several changes after delivery. This includes the shrinking of the uterus, shedding of the uterine lining, closing of the cervix, returning of the vagina to its normal size, etc. Mothers are also prone to psychological changes during the postpartum period [3]. This is usually due to one or a combination of issues, including coping with breastfeeding, fear of body changes after delivery, financial pressure, being deserted by a partner, isolation, lack of family or social support, and no experience of a maternal role model [4]. The

newborn baby also undergoes changes in general appearance, reflexes and weight. For most mothers (particularly first time mothers), these changes can be a source of considerable concern and may contribute to a number of adverse health conditions [5–7]. For these reasons, postpartum care services are of utmost importance in preventing adverse health outcomes for mothers and their newborn babies. Thus, it is important to understand mothers’ perceived quality of the postpartum care they receive, which is the rationale behind this study. This study was a pilot investigation of mothers’ perceptions of the quality of postpartum care services in LW district, an urban district in Central Shanghai, China. The

Address reprint requests to Dr J. E. Ehiri, Department of Epidemiology and International Health, School of Public Health, University of Alabama at Birmingham, 1665 University Boulevard, Ryals Building 217, AL 35294-0022, USA. E-mail: [email protected]

 2002 International Society for Quality in Health Care and Oxford University Press


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objectives were to describe current postpartum services in the district and to investigate mothers’ perceived quality of the services so that results obtained might be used to identify good practice, and to suggest areas that require improvement.

Postpartum health services in China In the Chinese health system, the overall postpartum period is 6 weeks after delivery. Records for all maternal and child health services were not available in the study district until 1973. Before 1973, postpartum services in the district were provided to mothers only whilst they were in the hospital after delivery. Average stay in the hospital for uncomplicated deliveries was usually approximately 5 days. During this era, mothers were not followed up with home visits after discharge from the hospital, but were required to attend health facilities for postpartum care. In China, as in many other countries, post-delivery hospital stays have become shorter (now 1–3 days), and anticipation of concerns that may arise and followup care by community health workers have become crucial. In 1973, the LW district maternal and child health hospital decided to extend postpartum care services to the community where mothers receive care during home visits. Mothers register before delivery in maternal and child hospitals, and are given a postpartum card. Three home visits are provided for each postpartum mother in addition to one hospital check-up. The schedule of visits is as follows: (1) Between the 3rd and 7th day after discharge from hospital. (2) On the 14th day after delivery. (3) Between the 26th and 28th day after discharge. These visits are followed up by a check-up in the hospital on the 42nd day after discharge. Mothers have to visit the health facility for the day 42 check-up. During each postpartum home visit by health workers, mothers and their new babies receive care in accordance with the provisions of the government postpartum guideline (Table 1). The guideline is intended to help ensure uniformity of services provided to all mothers. Each postpartum health care worker has a kit that contains equipment needed for examination of mothers and their babies, including stethoscope, thermometer, forceps, weighing scale, gloves, antiseptics, and torch. Postpartum mothers also receive health education on mother and child health. Mothers and babies requiring further medical attention are referred to the district maternal and child hospital for check-up and treatment. Several studies have been conducted on reproductive health services in China, but most have centered on family planning activities [8,9], to the detriment of postpartum services. In particular, since the baby-friendly initiatives of the 1990s, there has been no indication of published studies on mothers’ opinions about the quality of postpartum services in the district. This study was an attempt to fill this gap in knowledge, with the hope that its findings might help to identify good practice and areas that need improvement.


Methods Study setting The study was conducted in LW district, Central Shanghai, China, between July and September 1999. LW district is located directly south of People’s Square. It covers an area of 7.5 km2 and has a population of 400 000. Many of Shanghai’s high quality residential and commercial infrastructures are located within the district. It is a relatively affluent urban district of China, with good health and socioeconomic indices. It covers four subdistricts: DP, WLQ, RG, and HHZL. Each township has one maternal and child health post. The study was conducted in DP and RG subdistricts. The two subdistricts were chosen on purpose for their representativeness of the district in terms of health and socioeconomic indices. Owing to difficulties with accessing mothers at home during the study period, the study was health facility based. Data were collected at the two maternal and child health posts in the two subdistricts, the main providers of postpartum care services. Sampling Participants in the study were postpartum mothers from the two subdistricts in the district. All who received postpartum care by health providers in the subdistricts between December 1998 and July 1999 were eligible for inclusion in the study. From an overall sample frame of 80 eligible postpartum mothers in the two subdistricts, 63 attended the health posts during the study period. Thirteen of these were unable to participate in the study due to pressure on their time. Fifty (63%) participated in the study. These were those presenting to health posts for either check-up or immunization of their babies, and who agreed to participate in the study. Of these 50, 27 were from the DP subdistrict township and 23 were from the RG subdistrict. Study instrument The study instrument, ‘questionnaire on mothers’ perceived quality of postpartum care services in Luwan district, China’, was developed in Liverpool (UK) in consultation with the Chinese collaborators. It consisted mostly of open-ended questions that were designed to allow mothers to structure their perceptions in their own words. Items covered included, among other things, basic demographic data (age, parity, educational level, delivery date, place of delivery, occupation, and township). Other items included whether or not the mother received postpartum service as stipulated in the official postpartum care guideline, the importance that mothers attach to different aspects of postpartum services, the nature of the interaction between the mother and the health workers, mothers’ definition of quality, whether they were satisfied with the quality of service they receive, and a discussion of their statement on this. The questionnaire items were drafted following a review of the literature and preliminary interviews of mid-level Chinese health workers undertaking postgraduate studies in

Postpartum care in Central Shanghai

Table 1 Content of postpartum care in LW District, China Ask for: Examination of: Health education on: ............................................................................................................................................................................................................................. 1. For mothers (a) Temperature (a) Room cleanliness (b) Blood pressure (b) Breastfeeding (c) Breast (c) Baby’s: (d) Uterus mouth care (e) Lochia skin care (f) Vulva buttock care (g) Hygiene advice diaper handling (h) Referral for complications temperature room ventilation others 2. For babies (a) History of breast-feeding (a) Weight (b) Amount of mother’s milk (b) General condition (c) Baby’s appetite, sleep, and stool (c) Color of face1 (d) Head (e) Skin (f) Genitalia (g) Congenital malformation (h) Nose (i) Mouth (j) Heart (k) Lung (l) Abdomen (m) Navel (n) Genitalia (o) Congenital malformation 1

To check for newborn jaundice.

public health in Liverpool. The instrument was modified and finalized in China following discussion with local health workers, and a review of the government guidelines for postpartum services. Two independent bilingual Chinese translators then translated the instrument into Chinese. Their translations were compared for consistency by a third bilingual Chinese translator, and translated back into English. The interview schedule was pre-tested by means of a small pilot study of six postpartum mothers in China, who were not included in the main study. Modifications were made to incorporate lessons learnt from the pre-test in order to ensure collection of quality information from the mothers. Data collection Ethical approval was obtained before commencement of the study from the ethics committee of the Liverpool School of Tropical Medicine and from the local ethics committee in Shanghai, China, through the Department of Maternal and Child Health, School of Public Health, Fudan University Medical Center (formerly Shanghai Medical University). Data were collected from postpartum mothers in health facilities. The first author and a local research assistant interviewed mothers in the health posts. The research assistant was a graduate health worker with research experience in the area of maternal and child health, and was fluent in English and

Chinese. To ensure the quality of data collection he was trained in the rationale and methods of the study before it commenced. The interviews were conducted in Chinese after obtaining informed consent of the mother. Interviews lasted an average of 45 minutes each. Each set of data collected was transcribed and translated into English on a daily basis by the research team. Data analysis Quantitative data (mainly descriptive data) arising from the interviews were analyzed using Epi-Info 6.04 [10], while qualitative data were analyzed using the content analysis method [11]. In reporting the results, direct quotations by mothers were used to illustrate the opinions they expressed.

Results Characteristics of the study population The study population comprised 50 postpartum mothers from a sample frame of 80 mothers; a response rate of 63%. The two key postpartum care providers for the study subdistricts were interviewed regarding the non-responding


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Table 2 Characteristics of the study participants No. (%) (n=50) ............................................................................................................ Educational level Primary 3 (6) Junior 6 (12) Secondary/mid-professional 27 (54) College/university 13 (26) Graduate 1 (2) Occupation Home-maker 6 (12) Employed 38 (76) Self-employed 6 (12) Parity One 45 (90) Two 4 (8) Three 1 (2)

Table 3 Frequency of postpartum examination received by mothers

Characteristics of mothers

Figure 1 Frequency of postpartum visits received by mothers. mothers. The results did not highlight any marked difference between those who participated and the non-respondents in terms of age, parity, education, and health condition. The mean age of mothers was 28 years (range 20–38), while the mean age of their babies was 3.8 months. Most (90%; n= 45) were first-time mothers. Over half of the mothers (54%; n=27) were educated to secondary school level, and were mostly government and company employees. All the mothers had their babies in a hospital. Half (n=25) underwent normal delivery and the other half delivered through caesarean section. Average length of stay in the hospital was 2 days (range 1–3 days for those who had a normal delivery), which increased to an average of 6 days for those who delivered by caesarean section. Table 2 summarizes the characteristics of the study participants. Current postpartum care services received by mothers Postpartum care services provided for mothers and their babies included follow-up home visits, medical examinations, and health education on maternal and child health issues. As already noted, the standard number of postpartum home visits set by the district maternal and child health department is three. However, as shown in Figure 1, some mothers


Postpartum examination

No. (%) (n=50) ............................................................................................................ Temperature Yes 49 (98) No 1 (2) Blood pressure measurement Yes 25 (50) No 25 (50) Breast Yes 45 (90) No 5 (10) Uterus Yes 41 (82) No 9 (18) Lochia Yes 42 (84) No 8 (16)

received only two visits (34%; n=17, four of whom were still in their postpartum period). A few others (10%; n=5) received one visit, including two mothers who were still in the postpartum period. According to the reports of the mothers, most received all prescribed examinations, with the exception of blood pressure measurement, which was received by only half of the mothers (Table 3). With regard to advice concerning postpartum care, the majority of the mothers reported that they received sufficient postpartum advice, which they considered very helpful (Figure 2). This included advice on nutrition (94%; n=47), exercise and fitness (86%; n=43), personal hygiene (96%; n=48), contraception (68%; n=34), and a reminder about the importance of the day 42 check-up (86%; n=43). Medical examination of the newborn baby is one of the most important constituents of postpartum care in the district. Almost all mothers (98%) stated that their babies were examined during postpartum home visits. One of the roles of the postpartum care provider is to question mothers about their babies. This helps care providers to carry out health education and to provide advice according to the individual needs of the mothers. All of the mothers reported that they were asked questions concerning their babies, including on such issues as baby’s feeding patterns, particularly whether breastfeeding or bottle-feeding, appetite, sleep, stool, and amount of milk produced by mother. The content of educational messages given to mothers by health workers is shown in Table 4. Postpartum care services considered important by mothers The majority of the mothers stated that advice about their babies (86%; n=43) and medical examination of babies (82%;

Postpartum care in Central Shanghai

Figure 2 Health advice received by postpartum mothers.

n=41) were the most important and helpful postpartum services they received. When asked of other services they would have liked to receive during postpartum services, but which were not provided, only a few (10%, n=5) expressed the need for postpartum counseling directed at the mother’s own health. Postpartum problems encountered by mothers Mothers were asked to state the health problems they encountered during postpartum period. This was important to identify whether there was need for extending, revising or adjusting the service. Almost all mothers (96%; n=48) reported that they encountered some problems (Figure 3). The most common of these related to care of the newborn (54%, n=27), anxiety (44%; n=22), and stress (40%; n= 20). One mother described how she became fat after delivery, in spite of the fact that she was taking regular exercise. Another mother narrated how nervous and worried she was during her first days after delivery. Two described difficulty with breastfeeding, which resulted in their preference for bottle-feeding. Mothers generally had concerns about their babies’ health. In describing these concerns they indicated, for example, that they did not know how many times they should feed their babies. Some of their typical responses were: ‘My child does not cry often so I do not know when he is hungry’; ‘I don’t know when and how to wean a child’; and ‘I don’t know how to balance the food of my child’. They also described difficulties in differentiating between normal and abnormal attitudes of their babies. One of the mothers said ‘. . . my baby keeps waking up suddenly at night and I don’t know if this is normal’.

Mothers’ opinions on quality of current postpartum care services When asked their opinion on the quality of current postpartum care services, 25 mothers (50%) indicated that they do not consider the services to be of high quality. When asked why, to elaborate upon this, they defined high quality as ‘full satisfaction of mother and the child’. Some of the reasons given by the mother for their response were: ‘. . . care providers don’t usually give us correct and reliable messages’; ‘they are usually in a hurry during postpartum home visits’; ‘In times of need, they are difficult to be found or to be contacted’; ‘They are very brief in giving health education’; ‘They do not provide health education materials’; and ‘They do not follow us up regularly when we have postpartum problems’. There was agreement among the mothers that current postpartum care services need improvement to enhance quality. They indicated that care providers need more training on childcare. According to the mothers, postpartum information given to them was very brief, and medical examination and follow-ups were limited. Concerning time for postpartum service delivery, five mothers said that it was too short, resulting in limited provision of postpartum examinations and health information. One of their typical responses was ‘I had a lot of questions to ask the care provider concerning my baby during the home visit, but the care provider was always in a hurry to go for her next visit’. When asked their opinion about current postpartum care in relation to accessibility, they stated that this was not a problem. The few who lived far from the health facilities indicated that they could easily afford transportation costs.


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Table 4 Content of educational messages received by mothers concerning their babies Postpartum examination

No. (%) (n=50) ............................................................................................................

Hygiene Yes No Breastfeeding Yes No Mouth care Yes No Skin care Yes No Navel care Yes No Buttocks Yes No Body warmth Yes No Suffocation Yes No Good ventilation Yes No

43 (86) 7 (14)

The mothers were asked how quality of current postpartum care could be improved. A majority expressed the need for more advice about childcare (76%; n=38), health education materials (58%; n=29), home care visits in times of need, and not just the officially prescribed visits (36%; n=18). The need for employment of more qualified health personnel was also mentioned (Table 5).

45 (90) 5 (10) 24 (48) 26 (52) 33 (66) 17 (34) 40 (80) 10 (20) 42 (84) 8 (16) 37 (74) 13 (26) 28 (56) 22 (44) 32 (64) 18 (36)

Figure 3 Postpartum problems reported by the mothers.


Mothers’ suggestions for improvement of quality of postpartum services

Discussion This study addresses an important, but largely neglected component of reproductive health. Although a plethora of studies have been conducted on the subject of reproductive health in China, our review of the literature shows that very little attention has been paid to postpartum health. The arrival of a new baby is a time of joy. Yet, for many mothers (especially first time mothers), it is a time of fear, confusion, and sometimes isolation [4,5]. Few are prepared for the physical and psychological challenges in the weeks and months after delivery, and clearly the postpartum period represents a time of stress, a situation cross-culturally characterized by the need for immense physical and emotional support, and a period linked with high levels of maternal morbidity [30]. Study sample The 50 mothers (out of 80) who participated in this study represent a response rate of 63%. The main reason why the remaining 37% (n=30) did not participate in the study was time pressure. In an effort to understand whether these mothers who did not participate in the study were different

Postpartum care in Central Shanghai

Table 5 Mothers’ suggestions on ways to improve quality of postpartum care Suggestion

No. (%) (n=50) ............................................................................................................................................................................................................................. More advice about childcare to be provided during postpartum visits 38 (76) Health education materials about mother and childcare to be provided during postpartum visits 29 (58) Care providers to be able to visit mothers in times of need, and not just 18 (36) during officially prescribed times Provision of in-service training for existing staff, and employment of additional qualified staff 17 (34) Extra home visits to be provided to mothers after postpartum period up to the third month 15 (30) Time spent by health workers during postpartum visits to be increased to give 11 (22) care providers enough time for delivering the services Direct personal contact with care providers (rather than by telephone) in time of need in 8 (16) order to assure mothers Mothers club to be opened in the community where postpartum mothers can come together 4 (8) to share their experiences, discuss, ask questions and receive lectures More advice about breastfeeding should be given 3 (6) Mothers with postpartum problems should have extra postpartum home visits 2 (4) and frequent follow-up Care providers should normally give necessary advice about mother and childcare, 2 (4) not only when asked Care providers’ advice on childcare should be clear and in sequence 2 (4)

Note: total numbers exceed 50 because of multiple responses.

from those who participated, we interviewed the two postpartum care providers for the study subdistricts, since they have a personal knowledge of the mothers as well as access to their socio-demographic data. Results of this interview did not highlight any marked difference between the nonrespondents and the study participants in terms of age, parity, education, and health condition. Thus, while the level of response in this study is a factor for consideration in interpreting the results, we do not have any reason to believe that the non-respondents were different from the study participants. Delivery by caesarian section It was interesting to note that half of the mothers delivered by caesarean section. The steady rise in caesarean section rates is an emerging area of concern in reproductive health and a matter of international attention, given that the trend is no longer confined to western societies. We have no evidence to suggest that mothers who participated in this study are different from the population of women of childbearing age in urban China. Recent studies in China [13] have demonstrated increases in the rate of caesarean section in the country, especially among young mothers [14]. Studies from other parts of Asia [15,16] and many parts of the developing world [17,18] have also shown marked increases in the rates of women choosing to deliver by caesarean section. In many societies it has become a matter of individual choice for the woman [19,20].

Frequency of postpartum visits received by mothers The use of a standard guideline by postpartum care providers in the district is a commendable approach since it is intended to help ensure uniformity in the standard of service given to all mothers. However, it was interesting to note that although the official guideline prescribes three home visits, barely half of the mothers received the three visits. With the exception of six mothers who were still in their postpartum period, evidence from interviews with the mothers suggests that the main reason why some did not receive the three prescribed visits was pressure on the time of health workers. It is possible that health providers prioritize their visits in accordance with their perceived needs of each individual mother. However, this will need confirmation by a study of health providers in the district. Postpartum problems encountered by the mothers The problems reported by the postpartum mothers were related mainly to care of their babies, stress, and anxiety resulting from their limited knowledge about childcare, and their changing role and body image. The problems expressed by these mothers are similar to those known to have been encountered by postpartum mothers in similar urban settings around the world, including in western societies [21,31]. For example, the following is a list of common complaints reported by new mothers in western settings [21]:


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(1) (2) (3) (4) (5) (6) (7) (8) (9)

Reduced sleep by the mother Fatigue Baby up every few hours for 6 weeks On call 24 hours Baby sleeps but constant vigilance is required Loss of freedom Unpredictable schedule Physical pain/sore breasts/episiotomy Increased workload, e.g. laundry

These may reflect the lack of social support that many parents living in urban settings experience compared with those immersed in rural cultures with extended family ties and more social support. These complaints might prove to be valuable insights for health care professionals in terms of targeting their time and resources towards the area of greatest need for the postpartum mothers. Mothers’ opinion on quality of current postpartum care services Considering the health implications of the postpartum period, both the content and quality of services provided to mothers and their babies during this period deserve special attention. However, in many developing countries, quality of care has not been a priority issue [22]. It is only recently that health planners and donors in developing countries are beginning to focus on it [22]. As Reerink and Sauerborn [23] observe, assessing and improving quality of healthcare was, until recently, a low priority, both for policy makers in developing countries, and for donor agencies. The reasons for this are apparent: (1) priority of coverage as compared with quality amidst limited resources; and (2) the view that quality is difficult to assess in the absence of reliable data and effective health information systems. As this study has demonstrated, mothers’ perceived quality of postpartum care in the study setting was related to their concerns about care of the newborn, and hence they defined quality as ‘full satisfaction of the mother and child’. As first time mothers in an urban setting, and who may not have the cultural and family ties found in rural settings, they may lack knowledge and information about childcare, and hence their increased need for information and assistance in this area. Mothers’ responses to the question ‘How do you think care providers can help you solve such problems?’ lend further insight into their perceived need for additional information on childcare, and more time to interact with health workers during postpartum home visits as shown in Table 5. The results showed that most mothers appreciate the usefulness of the service being provided, but noted areas for further improvement. They assessed care providers’ skills as lacking in some areas, particularly health education on childcare. Mothers assessed postpartum examinations and followups provided as good, but limited. Postpartum information given was perceived as brief, and no literature was provided to mothers during postpartum visits. The need for literature for postpartum mothers may be apparent in such an urban setting as Shanghai, but this may not be the case for mothers in rural China, where the levels of illiteracy are higher [24].


The postpartum mothers also indicated the need for further training by health providers. A study in Lesotho reported that the skills of health personnel and their reputation were important factors in the use of health facilities, and this may have implications for patients’ assessment of quality of the care that is provided. Inadequate skills of health workers often feature among people’s complaints about the quality of health services [25]. It should be noted, however, that it might not always be possible for any individual health worker to have answers to every question posed by postpartum mothers. Having said this, it is pertinent to note that useful training resources that can be adapted to the cultural needs of postpartum mothers in China are available, including Postpartum Care of the Mother and the New Born: a Practical Guide published by the World Health Organization (WHO) [12]. According to the mothers, important aspects of the postpartum service include good interpersonal relationship with care providers, and access to care in times of need, rather than during officially prescribed visits. Again, it is important that maternal and child health workers spend more time with the mothers during postpartum home visits as this is likely to improve mothers’ rating of the quality of care. However, the resource implications of this should be recognized, especially as it seems that health workers are already prioritizing their time for the benefits of mothers in greater need. In particular, unless more maternal and child health workers are employed, spending more time on each visit as demanded by the mothers may jeopardize the ability of existing staff to reach all mothers. It was apparent that mothers had greater expectations of help from health workers compared with what is provided. This disparity between mothers’ expectations and the level of service provision became apparent to health services planners in the region only after presentation of the results of this study. This underscores the importance of consumer feedback in health services planning. In many developing countries, the small amount of focus on quality of care has been on providers’ viewpoints, with professional standards being used as the yardstick for measuring quality [26–28]. The health care system is not just a configuration of providers. Consumers are an integral component, and if the system fails to produce quality, it is because consumers have not acted concertedly to exercise their rights and bear their responsibilities [29].

Conclusion The study findings highlight the importance of consumer feedback in maternal and child health. The findings effectively indicate areas of postpartum services for improvement, and the ways to reduce barriers that exist in the provision of care. In interpreting the results of this study, it should be noted that the sample size is small, and the investigation was conducted in a relatively affluent urban district that may not represent the true picture for much of China, particularly the rural poor districts. However, this does not detract from the

Postpartum care in Central Shanghai

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value of the study since it is one of few empirical attempts to describe mothers’ opinion on the quality of postpartum care in the district, and one of the few documented evaluation studies of postpartum care services in the district. The findings will be relevant to health workers and policy makers involved in planning and implementation of maternal and child health services in similar urban settings in many developing countries.

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The authors are grateful to the postpartum mothers and health providers who participated in this study. Development of this paper was made possible through financial support from the Ken Newel Award, Liverpool School of Tropical Medicine, Liverpool, UK.

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Accepted for publication 5 June 2002