Category: Postpartum Care

In ten years (i.e. by 2030), we should have worked hard enough to decrease the global maternal mortality ratio from 216 to below 70 deaths out of every 100,000 live births in order to meet the Sustainable Development Goal on maternal mortality. One of the indicators for measuring this goal is the proportion of births attended by skilled health personnel, commonly referred to as a skilled birth attendant (SBA). Globally, a major focus of safe motherhood interventions has been to increase the number of deliveries by skilled birth attendants. Skilled birth attendants are typically doctors, nurses, or midwives who have the competence to provide quality care to women and newborns. Skilled birth attendants must have the ability to promptly identify and manage pregnancy, delivery and postpartum complications or refer to an appropriate level of care/health facility. This is important because timely identification and management of complications is critical in decreasing maternal deaths. Most maternal deaths are due to complications such as hemorrhage, hypertensive disorders, infections, and other complications from delivery. Most of these complications can be adequately managed if a woman has timely access to a skilled health professional.

Sub-Saharan Africa has shown progress in the number of births in the region attended by a skilled birth attendant, with 59%  of births between 2012 and 2017 attended by a skilled health professional . Globally, 80% of births are attended by a skilled health professional. There remains work to be done to ensure that more women have access to skilled health professionals during pregnancy, childbirth, and postpartum.

While it is important that women have access to and actually use the services of skilled health professionals, it is equally important that providers actually have the knowledge and skill set to identify and manage women’s conditions appropriately. Poor knowledge of postpartum care and potential complications directly impacts the ability of midwives to provide quality care to patients after childbirth. An important question we must ask is “how skilled are our skilled health personnel?”

Findings from our survey of 245 midwives in Ghana revealed significant knowledge gaps among midwives related to postpartum care and postbirth warning signs, immediate newborn care, and management of complications. Most midwives gave incorrect answers on postpartum care questions related to location of fundus, postpartum examination, and care during the first 2 hours after birth. While most midwives were knowledgeable about breastfeeding and immediate hemorrhage intervention, many lacked knowledge on cord care, thermal protection, newborn resuscitation, contraindications for vacuum extraction, treating metritis, and performing a cervical repair. Our findings also revealed significant knowledge gaps on recognition of warning signs of life-threatening complications such as pulmonary embolism, cardiac events, and postpartum depression. More specifically, only 47.5%, 57.0%, and 57.0% of midwives were able to identify pain in chest, obstructed breathing, and thoughts of hurting oneself as warning signs of postpartum complications respectively.

The postpartum period is high-risk for maternal mortality. There is a need for additional training of midwives in how to care for postpartum patients and accurately identify warning signs of life‐threatening complications after childbirth. We found that more years of experience was a significant predictor of midwives’ knowledge. Thus, there must be comprehensive onboarding training programs for new midwives, as well as frequent in-service trainings on postpartum care, newborn resuscitation, and potential postpartum complications. We will not make significant progress in decreasing maternal deaths if our maternity care providers do not have the supposed knowledge, skills, and confidence to recognize and manage complications in a timely manner.

Postpartum care is care provided to a woman within 6 weeks or 42 days after birth. The World Health Organization recommends that postpartum care should be provided by a skilled health personnel, such as a doctor, midwife, or nurse in a health care facility. Postpartum care is very important because it helps in the timely identification and management of postpartum complications.

Lack of or inadequate postpartum care has become an issue of major concern, especially in developing countries. Most maternal deaths occur in the postpartum period from complications such as severe bleeding, infections, hypertensive disorders, and complications from delivery and unsafe abortion.

Many women do not receive any postpartum care after birth despite high maternal death rates in the postpartum period. Many researchers have conducted studies in several developing countries to determine the barriers to postpartum care after birth. I conducted a review of the literature to synthesize research findings on why women do not use postpartum care services in developing countries.

In this post, I highlight the most common reasons why women decide not to seek postpartum care after birth, summarized below.

• The view that postpartum care is not necessary/needed
• Lack of support or encouragement from husband or family
• Cost of services
• Lack of awareness of postpartum care
• Cultural barriers
• No complications and no awareness of complications
• Lower level of women’s education
• Women’s farming occupation or unemployment
• Lower level of husband’s education
• Husbands farming occupation or agricultural work

Participants in several studies reported that they did not seek postpartum care because they thought postpartum care was not necessary; they did not have support from husbands or family members; they could not afford the cost of postpartum services; they did not know about postpartum care; and they could not seek care due to cultural barriers. These barriers call for community-based health intervention programs. Some of the interventions could focus on educating women on the importance of postpartum care, the timing of postpartum care visits, and why they should attend visits even when they “feel fine” or do not observe any immediate signs of complications.  Community campaigns should also encourage support from husbands and family members to women to motivate them to seek postpartum care. In addition, clear guidelines on when women should return for postpartum visits after birth should be communicated to them prior to their discharge from health care facilities.

Findings from the review also indicated that women are less likely to use postpartum care services if they had no complications or no concern about complications, if they or their husbands are less educated, and if they or their husbands are farmers or involved in agricultural work. This points to the importance of educating not only women, but also their husbands, about warning signs of postpartum complications and when to seek care. It is equally important that women and their husbands are educated to return for their postpartum visits even if the woman did not have any complications during birth. This is because life-threatening complications are usually unpredictable and may require rapid action. Finally, interventions to encourage postpartum care use should target uneducated families and farming communities.

For the full article, see: 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 & Neonatal Nursing, 47(3), 371-384 (https://www.sciencedirect.com/science/article/pii/S0884217518300212).

 

 

There seems to be a lot of confusion in the use of the terms postpartum care and postnatal care. I recently conducted a literature review on factors affecting the use of postpartum care in developing countries. During this review, I noticed that while some authors used postnatal care to refer to care provided to the baby and mother, others used the term to refer to care provided to the mother. However, care provided to the mother should be referenced as postpartum care, not postnatal care.

Even among academics, postpartum care and postnatal care have been used interchangeably. The only thing postpartum care and postnatal care share in common is the period during which care is received – after the birth of a baby. A widely accepted definition of the postpartum and postnatal periods is the time immediately after birth to 6 weeks after birth of a baby. A common confusion in the use of the terms postpartum care and postnatal care stems from the reference to timing. To the extent that both terms are pointing to time after birth, they can be used interchangeably. However, postpartum care and postnatal care have different connotations when it comes to who is the intended recipient of the care provided. Specifically, postpartum care refers to care provided to the mother after the birth of a baby, while postnatal care refers to the care of the baby after birth.

The interchangeable use of the terms antepartum care and antenatal care may help explain why so often postpartum care and postnatal care lose their distinct meanings. Antepartum care is care given to pregnant women from conception to the onset of labor. Care during this period is also called antenatal care or prenatal care. The interchangeable use of antepartum and antenatal (prenatal) care makes sense because during this time, the woman is pregnant with the baby, and care for the two is not entirely separate. It is much more important to be specific in the period after birth because care for the mother after birth is quite different from care for the baby, whether in the immediate postpartum period or at follow-up visits. Postpartum visits are usually provided through the woman’s obstetric office, while a pediatrician is responsible for the baby’s health and well-being. In developing countries, although both postpartum and postnatal care may be provided by the same maternity care provider (most commonly a nurse/midwife), care provided to the mother is still different from care provided to the baby.

It creates a lot of confusion and makes the maternity care literature difficult to navigate when there is no clear distinction between postpartum care and postnatal care in the literature. One should not have to read a significant portion of an article just to determine whether the study was focused on care for the mother, care for the baby, or both. The term postpartum care, NOT postnatal care, should be used to reference care of the mother, at all times. This I believe, will make the literature clearer and easier to navigate.

More importantly, distinctions between the two should be made clear to patients, since postpartum care is often a neglected aspect of maternity care. Many women are aware of the need for postnatal care for their babies, but not the need for postpartum care for their own health and wellbeing. From my integrative review, the view that postpartum care is not needed and a lack of awareness about postpartum care were frequent reasons women gave for not attending postpartum visits.

Let’s be specific in terminology, and let’s be specific in informing patients about the need and importance of postpartum care!

Postpartum care in developing countries is beginning to gain a lot of attention as statistics show that the majority of maternal deaths occur during the postpartum period. Researchers, including myself, are busy trying to understand the fundamental reasons behind poor access to and delivery of postpartum care in Sub-Saharan Africa, a region where many women do not receive postpartum care after childbirth.

Current empirical evidence shows that socio-economic, demographic, and geographic factors can explain access to postpartum care. In particular, low level of education or illiteracy is associated with less use of postpartum care, as are residence in a rural area and farming as major occupation.

One of the questions of growing interest is: why do women decide not to return to health facilities for recommended postpartum care? Aside socio-economic factors, scholars are discovering that lack of women’s autonomy to make decisions, lack of husband support, and limited access to postpartum information or lack of awareness, tend to prevent women from seeking timely postpartum care.

Paying attention to barriers to postpartum care use is commendable, and has enhanced our understanding of areas to target for interventions. However, much less attention has been paid to the extent to which nurse/midwife advice influences women to seek postpartum care. My work in Malawi has showed that nurses/midwives serve as an important medium for postpartum information flow to women and their families, and may be one avenue to improve the use of postpartum care.

My research on the use of postpartum care, conducted in central Malawi has targeted rural subsistence farmers, a vulnerable population with even lesser use of postpartum care as the research evidence suggests. To my surprise, I found that almost all the participants in my study returned for the recommended one-week postpartum care visits. I asked a follow-up question: “why did you decide to seek postpartum care in the health facility?” The top reason women gave for deciding to return for their recommended postpartum visit, was that they were advised by the midwife to return!

This highlights the importance of midwife advice in improving postpartum care use. Nurse/Midwife advice to patients and their family to return to a health facility for postpartum care per country or WHO guidelines, is a simple, inexpensive intervention that could potentially improve postpartum care use among rural women in Sub-Saharan Africa!

Sub-Saharan Africa Carries the Greatest Burden of Maternal Deaths

Sub-Saharan Africa carries the greatest burden of maternal mortality. It is the region with the highest maternal mortality ratio (MMR), defined as the number of maternal deaths per 100,000 live births. According to estimates reported by the World Health Organization (WHO), Sub-Saharan Africa alone accounted for 62% of all maternal deaths globally in 2013. The same report indicated that the MMR in Sub-Saharan Africa is 510 compared to 140 in South-Eastern Asia, 85 in Latin America and the Caribbean, and 69 in Northern Africa. The rate of decline of maternal deaths has been slower in Sub-Saharan Africa than any other developing region. The majority of countries that made no progress or insufficient progress in meeting their Millennium Development Goal 5a targets of decreasing maternal mortality ratios by 75% by 2015were in Sub-Saharan Africa. It is of critical importance that the high maternal mortality in Sub-Saharan Africa be addressed.

Postpartum Care: The Often Neglected Aspect of Maternal Healthcare

The majority of maternal mortality cases occur in the often neglected postpartum period, defined as the time from 1 hour after delivery of the placenta to six weeks after delivery of the baby. The time of highest risk for maternal death is the immediate (first 24 hours) and early postpartum periods (days 2-7 after delivery). Life-threatening postpartum complications are often unpredictable and require rapid response. Postpartum care is essential for maternal health and survival because it enables skilled health providers, such as doctors and nurses/midwives to prevent potential postpartum problems, identify, and treat complications promptly.

The World Health Organization(WHO) recommends that postpartum care should be provided to mothers for at least 24 hours after birth in a health facility, and then at 48-72 hours, days 7-14, and six weeks after birth. Recommendations by the WHO on the content of postpartum care (for the mother) include physical assessment of the mother (vaginal bleeding, uterine contraction, fundal height, temperature, heart rate, blood pressure, urine void, etc.), counseling/information about the physiological process of recovery, iron and folic acid supplementation for at least three months, prophylactic antibiotics for women with third and fourth degree perineal tears, and psychosocial support. However, many women in Sub-Saharan Africa still do not receive any postpartum care. Percentages of women who do not receive any postpartum care after delivery in Sub-Saharan Africa remain very high, for example 74.1% in Uganda, 55.1% in Kenya, 55.2% in Nigeria, and 49.8% in Zambia. Obviously, these are missed opportunities for skilled health providers to prevent and detect any postpartum problems and complications in a timely fashion, and this can consequently lead to the death of a mother. Systematic and regular postpartum care is inadequate even for women who deliver in health facilities.

Call to Action

A need exists for more primary research on postpartum care provision and use in Sub-Saharan African countries. Research interventions during the postpartum period can decrease postpartum maternal mortality rates. To develop effective interventions that will decrease maternal mortality rates in Sub-Saharan Africa, it is critical to identify the key factors affecting postpartum care use, and understand challenges health facilities face in providing postpartum care. Research efforts must address access to care, especially for rural women. New research strategies are needed to ensure that mothers, especially those who are marginalized, have access to quality postpartum care services.

 

Statistics From:

Trends in maternal mortality: 1990 to 2013. Estimates by who, unicef, unfpa, the world bank and the united nations population division. Geneva, Switzerland.

Zureick-Brown, S., Newby, H., Chou, D., Mizoguchi, N., Say, L., Suzuki, E., & Wilmoth, J. (2013). Understanding global trends in maternal mortality. International perspectives on sexual and reproductive health, 39(1).

Wang, W.J., Alva, S., Wang, S.X., & Fort, A. (2011). Levels and trends in the use of maternal health services in developing countries: DHS Comparative Reports. Calverton; USA: ICF Macro.

WHO recommendations on postnatal care of the mother and newborn. Geneva, Switzerland.