Presented by Debra Bick, Research Fellow in Midwifery, Department of Public Health & Epidemiology, University of Birmingham.

Recent studies have shown that many women experience persistent health problems after childbirth (MacArthur et al 1991, Glazener et al 1995). Few women seek GP consultation, even though some symptoms are severe and affect aspects of their daily lives (Bick and MacArthur 1995). Routine postnatal care has altered little over recent decades. Studies which have investigated this suggest it does not identify or manage commonly experienced health problems. Limited information is available to guide midwives, despite a statutory duty to attend women for a defined period of time after birth (UKCC 1998).

The majority of women are offered a final consultation with their GP at 6 - 8 weeks, however this also appears to be based more on tradition than need, prompting the suggestion that it should be re-evaluated (Noble 1993). Recent reports highlighted the lack of detailed information on the outcome of postnatal care. The Audit Commission Report 'First Class Delivery' (1997) found little evidence of the clinical effectiveness of postnatal visits made by midwives, although they were popular with women.

IMPaCT is a randomized controlled trial, funded by the NHS Health Technology Assessment Programme, to develop and test the cost effectiveness of an alternative model of midwifery-led postnatal care based on individual need and the use of evidence-based guidelines. Forty general practices throughout the West Midlands region were randomized and the attached midwives continued to provide current care (control) or provided the new model of care (intervention). Women were recruited antenatally at around 34 weeks.

Midwives providing the intervention were asked to plan visits based on needs and only perform examinations and observations when there was a specific indication. The last planned visit was at 28 days. Checklists were used on two occasions during the 28 days to identify physical and psychological health problems. If a problem was identified, guidelines (devised by the study team) were used to assist in providing appropriate management, including criteria for GP referral. The midwife arranged a final consultation with the woman at 10-12 weeks postpartum, usually in place of the 6-8 week GP appointment.

Main outcome measures include women's general health and well-being as assessed on two validated health measures, the SF36 and the Edinburgh Postnatal Depression Scale. These are assessed at four and twelve months after delivery. Satisfaction with care is evaluated at four months and health problems documented at twelve months. Other outcome measures include breast feeding uptake, immunization rates and use of the health services by mother and child during the first year.

Recruitment to the trial finished in March 1999 and over 2,000 women have been recruited. Preliminary results should be available by the end of 1999. The trial will generate an enormous amount of information about postnatal care, and for the first time will also enable a detailed evaluation of current care.