A social policy expresses "ongoing strategies for structuring relationships and coordinating behaviour to achieve collective purposes...ways of exerting power, of getting people to do things that they might otherwise not do" [1]. The implementation of a policy requires that resources come from wherever necessary to enact the relevant program(s) and "that the economic structure, social institutions, and political processes will be shaped to protect and maintain that commitment" [2]. The purpose of this paper is to examine how a health policy initiative was implemented in two different parts of a single payer, government run health care system and to analyze the barriers and facilitators to achieving practice change.
The implementation of the 1999 policy-expansion of the Healthy Babies Healthy Children (HBHC) program, under the aegis of the government in Ontario, Canada, provided an instructive example of a policy intended to drive health care practice. The expansion of this universal program extended to women the option of staying in hospital for 60 hours following an uncomplicated vaginal birth for "assessment, support and follow-up purposes" [3]. The stated goal of the policy was to give "women some flexibility" in length of stay (LOS) in hospital after childbirth and to provide enhanced community-based postpartum services. This policy was in keeping with the 1996 recommendations of The Canadian Pediatric Society and the Society of Obstetricians and Gynecologists of Canada [4].
The policy prescribed a province-wide implementation mechanism for the community care portion of the policy that consisted of a public health initiated telephone call within 48 hours of postpartum discharge and the offer of a home visit to all mothers, regardless of their LOS, demographic profile or residential location in the province [3]. No specific implementation mechanism was prescribed for extending the LOS; hospitals were charged with developing their own implementation plans.
Grol and Grimshaw [5] categorized some of the environmental factors that may become barriers to the implementation of evidence in practice. The universal extension of the HBHC program through two distinctive components of the health care system, with different structural and functional accountabilities, provides an interesting opportunity to examine how contextual factors can act as barriers or facilitators, leading to very different implementation strategies and uptake levels.
These groupings provide a reasonable way of examining barriers to policy implementation at the practice level. The organizational, professional, and social contexts into which a policy is introduced may block or facilitate practice change. What happens at the level of implementation when a government imposes universal changes in practice standards not driven by, or even agreed to by, clinicians? What happens when the implementation of a policy is dependent upon two quite different segments of the health care system – hospitals and public health units – each sector controlled by different professions and operating from related, but different, mandates? What happens when women who are the objects of the policy are neither consulted nor required to be informed in any systematic way about the policy?
Far from being a new phenomenon, postpartum "early release" from hospitals for healthy mothers and newborn infants has been a contentious but familiar theme in both the practice and the politics of Canadian health care in the twentieth century [6]. By the mid twentieth century, in-hospital birth and postpartum care became the norm in North America [6]. This change in location from community to hospital was driven by a concern for the mother's health as much as a concern about infant mortality or morbidity. [7]
The shift from home deliveries to a hospital setting reached a peak in the 1960s [8, 9]. Within the first 50 years of the twentieth century, the high and well-known numbers of maternal deaths and injuries pushed physicians to do what they did best – to medicalize pregnancy and childbirth [6]. As with most medical advice, this practice was couched in terms of safety for mothers and infants; [8, 10]. Childbirth became firmly lodged within the mandate and practices of the 'sickness care system' [11].
Physicians prescribed 'lying in' for 14 days postpartum, in spite of evidence that suggested shorter hospital stays and getting out of bed sooner were better for the health of women [6, 8]. However, by 1949, according to Mitchinson, postpartum stays had decreased to an average of 10 days post delivery. 'Early rising' began to be debated and occasionally practiced during this time, mostly popularized by the post WWII increase in births and concurrent shortage of hospital beds [6].
From the 1970s through the 1990s, postpartum hospital stays shortened. In Canada, Wen reported the mean length of hospital stay after delivery decreased from 5.3 days in 1984–85 to 3.0 days in 1994–95[12]. In response to an expressed wish on the part of women and their partners, the practice of family-centred obstetrics led hospitals to develop early discharge programs to accommodate strong patient desires [8]. By 1999, the average length of stay for a "delivery in a completely normal case" (Code 650) was 1.8 days [13]. These developments mirrored similar changes in practice in the U.S. [14]. Decter reports that, concurrent to this, hospital stays for a variety of procedures and illnesses were becoming shorter as well due in part to emerging technology and changing practice standards and in part to fiscal restraints [15].
Similarly, public health nursing practice changed over time. In the 20th century, the mandate of public health expanded to specifically include improving maternal child health [16]. Public health continued to place emphasis on the health and well being of mothers and infants in many ways (e.g., 1998 Ontario Healthy Babies, Healthy Children Program). This program is a prevention and early intervention initiative intended to provide support and services to families with children from before birth up to six years of age that could benefit from additional resources. At the time the universal postpartum program was introduced, the HBHC program was already in place, with public health nurses engaged in calling and providing home visits for mothers and infants identified through in-hospital screening [17].
The 1990s were troubled years for the Canadian healthcare system and, consequently, for the governments which managed provincial operations [18, 19]. Increasingly, hospitals cared only for critically ill patients; convalescence occurred in the community with or without the support of community-based health care providers. At the same time, public health units in Ontario stopped routine visits to newborn infants and their mothers. By early 1998, an Ipsos-Reid poll found that 73% of Canadians believed that the healthcare system was worse than it had been 5 years previously [20]. Consumers and potential consumers of medical care services were expressing the fear that reductions in in-hospital care were compromising patient well-being.
These concerns extended to postpartum and newborn care. In Canada, in 1997, there occurred what has been defined as a "focussing event" – something that draws widespread attention and publicity to an existing problem [21, 22]. The accidental death of a newborn infant from dehydration led to a Coroner's inquest that raised questions about a connection between the death of a seemingly healthy infant and maternity short stay hospital policies [23].
The political lessons from this event were not lost on a Canadian government with a health care system under criticism. By 1998, the Government of Canada had created Family-Centred Maternity and Newborn Care: National Guidelines [24]. The guidelines made clear that, while early discharge programs had been judged safe, satisfying, efficient and economical for their users, the success of these programs rested on the following factors: parental choice, post-natal screening, community support components, and appropriately trained professional staff [24]. They go on to say that where "administrative mandates may give rise to a non-voluntary, short hospital stay", this must be coupled with community support strategies and a program of community follow-up care [[24] 6.36]. It is very clearly stated that "the mother...should decide the length of hospital stay, based on her individual needs" [[24] 6.36].
Facing an election call the Conservative Government of Ontario announced in their 1999–2000 business plan [25] their intention to give additional funding to hospitals for extending the stay of postpartum women and to the HBHC program for a postpartum telephone call and home visit [3]. This universal policy had the advantage of being potentially popular, apparently caring, medically harmless, relatively inexpensive and appealing to an already concerned public, media and professional community, even though evidence of efficacy or system capacity to implement the policy was not clear.
The Ontario Mother and Infant Survey (TOMIS) of mother and infant health and service utilization was completed just prior to the introduction of this policy. A replication study, TOMIS II, provided an opportunity to examine the outcomes of this policy and to search for the factors that shaped the uptake of the policy by providers and consumers.