How Skilled are Our “Skilled” Maternity Care Providers?

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 246 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.

Why Women Do Not Use Postpartum Care Services in Developing Countries

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 Nursing47(3), 371-384 (https://www.sciencedirect.com/science/article/pii/S0884217518300212).

 

 

Postpartum Care OR Postnatal Care? Let’s Get Specific!

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!

Decision to Seek Postpartum Care: The Power of Nurse/Midwife Advice

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!

Where are the Husbands? Male Participation in Maternity Care in Sub-Saharan Africa

The importance of male participation in maternity care in Sub-Saharan Africa is becoming increasingly important. This is because husbands have a role to play in ensuring that their wives’ obstetric care needs are met. The involvement of husbands in their wives maternity care is especially critical in Sub-Saharan Africa because in many settings of the region, husbands decide when and where obstetric care is sought, even during complications. It is therefore essential to understand and increase men’s involvement in their wives’ care in Sub-Saharan Africa. Since husbands are important decision-makers, an important first step is to increase their knowledge and awareness of obstetric care, to enable them to make informed decisions about where and when to seek care.

In Sub-Saharan Africa, cultural perceptions and gender norms often constrain men’s involvement and participation in maternity care. Maternity care in Sub-Saharan Africa is still seen by many as women’s business, and the role of husbands is often limited to providing financial and material support. This historically female-centered view of maternity care has led to lack of space to accommodate men in maternity care units in many health facilities. Further, maternity care providers easily exclude husbands from the education provided to wives prior to discharge from health facilities. Thus, male participation often ends at accompanying the wife to a health facility. As a result, husbands tend to have very little knowledge of the care their wives actually receive at health facilities, since they usually have to wait outside the health facility.

As part of my research on postpartum care in rural Malawi, I found that most husbands are unaware of routine postpartum clinical assessments such as blood pressure, temperature, abdominal, vaginal, and breasts exams their wives 20151006_143527receive in health facilities after delivery. Husbands who are aware of some of these services get the information from their wives. Also, many husbands do not usually attend postpartum care visits with their wives. Even for husbands who accompany their wives for care, they seldom enter the health facility.

An important finding was that the lack of knowledge of husbands and non-attendance at postpartum visits did not mean the husbands were not interested in the well-being of their wives. Many husbands permitted their wives to return for their postpartum visits because they were interested in her well-being. The non-attendance and lack of knowledge of postpartum care may be due to limited opportunities for husbands to participate in their wives care, because of the female-centered view of maternity care.

It is important to encourage husbands to support their wives in seeking postpartum care for the well-being of the wife. It is also important for health care providers to welcome husbands as partners in their wives care, when they accompany them to a health facility, by allowing them into private examination rooms (where available). For health care facilities without private examination rooms, health care providers can provide husbands with information on the status of their wives health. Maternal health education should be provided to both men and women, so that they are both equipped to make prompt, informed decisions about concerns that may arise, especially during obstetric complications. Further, women should be encouraged to have open discussions with their husbands about care they received in health facilities, and any health issues or concerns from visits.

Husbands’ participation in their wives maternity care, beyond accompanying wives to a health facility, could result in more knowledge and awareness of their wives health, and could enhance communication between husbands and wives related to obstetric care. This improved knowledge and communication may help in prompt decision-making for seeking emergency obstetric care, especially given the economic dominance and decision making power of men in Sub-Saharan Africa.

Time to Focus On Postpartum Care 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

Proportion of maternal deaths by days postpartum (Source: WHO technical consultation on postpartum-postnatal care)

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.