Investigating Patient Cognitive Load and Stress Levels During Postpartum Discharge

Life-threatening complications that occur after childbirth are often unpredictable and require rapid response, thus, all women who have a baby should be knowledgeable about the warning signs of potential complications. The bulk of patient education about potential complications and instructions for self-care and recovery is typically provided during discharge. The patients’ ability to understand and remember these instructions has many consequences for her health, especially her ability to identify warning signs of potential complications in a timely manner. Patients’ low cognitive load during discharge education after childbirth is important to ensure comprehension and understanding of their instructions. However, there is a scarcity of research on patients’ cognitive load and stress during discharge education. Using an assessment tool and skin conductance, we will investigate patients’ cognitive load and stress levels during discharge education after childbirth. Patient’s knowledge of potential complications will also be assessed before discharge education and 6 weeks after discharge.


Postpartum Complications: Women’s Knowledge and Impact of Post-Birth Discharge Education

The United States (U. S) has the highest maternal mortality rate among high-income countries. Obstetric complications, especially during the postpartum period, account for most maternal deaths. Once a woman leaves the hospital, the burden is on her to recognize when something is wrong, and seek appropriate care. A major contributing factor to the high maternal death rates is due to delays in seeking and receiving emergency care for complications. Women’s knowledge of the warning signs of potential complications impacts timely recognition and care-seeking for complications. However, little research has been done on knowledge of warning signs of complications among postpartum women across the United States. In this project, funded by the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN), we assess postpartum women’s knowledge of the warning signs of potential complications 4-6 weeks after childbirth in Georgia, a state with high maternal mortality in the U.S.


Midwives’ Knowledge of Postpartum Care and Complications in Ghana

A hospital in Tamale, Ghana

Midwives, the primary maternity care providers in many countries in sub-Saharan Africa, are instrumental in improving maternal/newborn health outcomes. The postpartum period (after birth) is a high-risk time frame for maternal deaths, and complications after delivery are the leading causes of maternal deaths worldwide. Midwives’ knowledge of postpartum care and potential complications determine the quality of care provided to women after childbirth, and is critical in the quest to decrease maternal mortality. In addition, it is essential that midwives provide education to the understanding of the patient on warning signs of potential complications after childbirth. This project is a survey of 245 midwives in the four main hospitals that provide inpatient maternity services in Tamale, Ghana. We assess midwives’ knowledge of postpartum care and post-birth warning signs, knowledge of immediate newborn care and management of complications, education provided to postpartum patients, and midwives’ perceptions of knowledge to teach patients about complications and skills to manage complications.

Peer-reviewed manuscripts from this project:

1. Adams, Y.J. & Ray, H. (2019). Knowledge of postpartum care and postbirth warning signs among midwives in Ghana. Birth: Issues in Perinatal Care. Doi: 10.1111/BIRT.12472

This study assessed midwives’ knowledge of postpartum care and warning signs of complications in Tamale, Ghana. The specific aims were to assess midwives’ knowledge of postpartum care, assess midwives’ knowledge of postbirth warning signs, and identify factors associated with knowledge of postpartum care and postbirth warning signs.

Results Summary:

The average number of correct responses on 10 questions related to postpartum care was 65.8%. Most midwives were knowledgeable about questions on breastfeeding. However, correct responses to questions on location of fundus (41.6%), postpartum examination (46.5%), and care during the first two hours postpartum (57.6%) were low

Midwives were asked to identify warning signs of postpartum complications: the overall average was 6.3 (out of 9) warning signs identified

Table from

Only 28.1% of midwives identified all nine warning signs of complications. Knowledge of warning signs of life-threatening complications (pain in chest, obstructed breathing, thoughts of hurting oneself) were low. Years of experience was the only predictor of knowledge of warning signs of complications.

Two other manuscripts forthcoming …

Use and Evaluation of Postpartum Care Services in Rural Central Malawi

Dr. Yenupini Joyce Adams with postpartum woman and newborn, Kandeu, Malawi

In this project, funded by the American Nurses Foundation (ANF) and the Center for Gender in Global Context (GENCEN) at Michigan State University, I interviewed subsistence farmers (husband-and-wife farmer dyads) in rural communities in Ntcheu district, Malawi. I explored reasons for their decision to seek postpartum care, evaluated postpartum care received after delivery in health facilities, and examined husband’s knowledge and attendance at their wives’ postpartum care. I used an interviewer-administered survey methodology, which was innovative in that I included husband-and-wife dyads and interviewed them simultaneously but separately. No other postpartum care utilization study in Sub-Saharan Africa had interviewed husband-and-wife dyads prior to my study, despite abundant evidence that husbands, as household heads, influence wives’ decisions to seek care.

Peer-reviewed manuscripts from this project:

1. Adams, Y.J. (2016). Use of postpartum care services in rural central Malawi.

This dissertation examines the use of postpartum care within the context of a developing country, and more specifically, among rural communities in central Malawi. It is a three-manuscript dissertation. Manuscript one, an integrative review, identifies factors affecting the use of postpartum care in developing countries, guided by the three delays model.

Adams, Y.J., & Smith, B.A. (2018). Integrative review of factors that affect the use of postpartum care services in developing countries. Journal of Obstetric, Gynecologic and Neonatal Nursing, 47(3), 371-384. doi: 10.1016/j.jogn.2018.02.006

Manuscripts two and three are described below.

2. Adams, Y.J., Stommel, M., Ayoola, A.B., Horodynski, M., Malata, A., & Smith, B.A. (2016). Use and evaluation of postpartum care services in rural Malawi. Journal of Nursing Scholarship, 49(1). doi: 10.1111/jnu.12257

This study examined women’s evaluation of postpartum care services (postpartum clinical assessments, health education, and midwife kindness) received from midwives prior to discharge in rural health facilities, and husband-and-wife-farmer dyads’ reasons for their decisions to return for one-week postpartum care visits in rural central Malawi.

Results Summary:

Most women reported receiving partial basic routine postpartum assessments such as fundal check, bleeding check, breast exam/soreness, blood pressure and temperature check. The results reveal the inadequacy of assessments offered to women in rural health facilities prior to discharge

Women’s Evaluation of Postpartum Assessments and Acts of Kindness received from Midwives

Despite inadequate care, 77% of women felt midwives paid close attention to them and 83% gave an overall positive evaluation (3.5-5 on a scale of 1-5). Participants stated prior negative experiences, or not perceiving a need for care (feels fine), may potentially prevent them from returning for postpartum care visits in a health facility.

Women returned for one-week postpartum care visits because they were advised by midwives to return for care, and also to make sure their babies were examined. The main reason why husbands permitted their wives to return for postpartum care was because they wanted their wives to be examined,  especially if they had a concern about their wives’ health.

3. Adams, Y.J., Stommel, M., Ayoola, A.B., Horodynski, M., Malata, A., & Smith, B.A. (2018). Husbands’ knowledge and attendance at wives’ postpartum care among rural farmers. Health Care for Women International, 39(9), 1020-1037. Doi: 10.1080/07399332.2018.1491976

This study examined husbands’ knowledge and attendance at their wives’ postpartum visit in a sample of rural husband-and-wife farmer dyads in central Malawi.

Results Summary:

Many husbands admitted they did not know about care their wives received in health facilities

 Percent agreement between dyad responses, restricted to dyads in which both husband and wife gave an answer of “yes” or “no”
% Agreement (n/N)*
N = 70
% Do not know (n)
Postpartum Assessments
Blood Pressure56.7 (17/30)57.1 (40)
Temperature40.7 (11/27)61.4 (43)
Abdominal Exam64.3 (18/28)60.0 (42)
Vaginal Exam/Checked Bleeding48.5 (16/33)52.9 (37)
Breast Exam/Soreness28.0 (7/25)64.3 (45)
Baby Exam74.5 (38/51)27.1 (19)
Table from publication: Doi: 10.1080/07399332.2018.1491976

The percent agreements between dyads were low. The odds of reporting that the woman received postpartum assessments were greater among husbands than among wives, meaning that husbands tended to say yes that their wives were assessed even when the wives were not.

Close to 60% of husbands did not go with their wives for their one-week postpartum care visits, with top three reasons being at work/busy doing other work, out of town, and did not see the need

We recommend that nurses/midwives should be encouraged to welcome husbands as partners in their wives’ care, by either allowing them into private examination rooms or providing them with information on the status of their wives’ health. Women should also be encouraged to have open discussions with their husbands about the care they received in health facilities, and any health issues or concerns from visits.