Policy & Stakeholders

Neonatal and child health

Postnatal care – a policy brief

Contributed by Dr Vijay Kumar (SWACH), Dr Suresh Dalpath (NHM Haryana), Dr Saket Kumar (MD NHM Haryana)

Post-natal period (birth up to 42 days after child birth) is a critically important period of life for the mother and the newborn baby for their survival. There is agreement to use this term in a uniform manner to highlight the importance of special care of both the mother and the newborn baby until at least 42 days after child birth. This recommendation should replace the terms used earlier e.g. post-partum, neonatal etc. The purpose of unification is to be able to have a common understanding amongst the providers as well as care givers. There is a need for a focus on the provision of care to the mother as well as the baby as a dyad.

According to WHO, almost half of all maternal deaths occur during the first day after child birth and 66% occur within the first week after childbirth. In 2013, 2.8 million newborns died in their first month of life─1 million of these newborns died on the first day. During the first month of life, the vast majority of newborn deaths (about 75%) occur during the first week of life. Through improvements in pregnancy care coverage and skilled birth attendance, the maternal mortality ratio has declined from 380 in the year 1990 to 210/100,000 in 2013. In contrast to the improvements in antenatal coverages and the increase in the proportion of skilled birth attendance, coverage during the post-natal period continue to be low. In the continuum of care, coverage for post natal care is the lowest as illustrated by countdown estimates.

Therefore, post-natal period is considered to be a black box in the continuum of care. An analysis of demographic surveys in 23 Sub Saharan countries showed that the coverage within 2 days after child birth was a dismal 13%.  The situation is not encouraging in South Asia also. The current post-natal visit coverage figures reflect a visit or a contact at around 42 days of child birth. This is too late and does not contribute substantially to the health or survival of mothers and newborn babies.

Besides the goal of reduction of neonatal mortality and maternal mortality, there are numerous benefits of strengthening of post-natal care. These include (a) improved breast feeding practices as well as higher exclusive breast feeding rates (b) laying the foundations for improved nutritional status of the mother and the child (c) improved health through child spacing (d) greater bonding and attachment between the mother (caregiver) and the baby. Good post-natal care contribute to lifelong health, happiness and productivity.

Post-natal care is a very critical part of the continuum of care. Its success depends on birth preparedness which should at the minimum comprise of an agreement about a place for safe child birth and the commitment to initiate early breast feeding. Its success would also depend on satisfactory management of child birth and active management of third stage of labor. However, filling up of this void is no easy task. There are numerous opportunities to increase the coverage and quality of post-natal care. Supportive policy and stakeholder participation are important for the success of post-natal care.

Based on a review of 27 projects, there are 2 key objectives of post-natal care. (1) a focus on reduction of deaths and complications in mothers and newborn babies and (2) counseling for promotion of healthy behaviors that impact on the mother and child. From the provider perspective, post-natal care can be rendered in the hospitals and health centers where child birth occurs and the proportion of child births in institutions is increasing. Post-natal care is provided predominantly through home visitation by trained health care providers. The timing of these contacts should be according to the risk for the mother and the newborn baby after child birth. The schedule for post-natal visits in home child births is as important as home visitation following discharge from the hospital/health center.

There are 3 broad approaches that should be considered in implementing post-natal care

3 Approaches

Approach 1:  Home visits carried out by professionally trained persons to provide a range of services that are focused on the mother and the newborn baby. This includes counseling and support to the family. These visits help to recognize problems and complications early that can be treated at home and there are situations when referral to a health facility becomes important to save the life of mother and or newborn baby. Counseling and support help in promotion and practice of healthy behaviors that include exclusive breastfeeding, use of family planning methods including exclusive breast feeding, iron folate tablet compliance (anemia is common in India), hygienic care, and timely immunizations. These interventions can help in implementing the complete package of post-natal care.

Approach 2: Home visits by trained community health workers. In India ASHAs have been given this responsibility. Amongst many efforts there are two relevant projects in India, that provide evidence for reduction of neonatal mortality through home visitations by community health workers. One of these projects showed reduction in neonatal mortality where the community health workers were trained to use antibiotics in the treatment of neonatal infections and they were trained to manage birth asphyxia. The adoption of this approach can be useful where referral is not possible due to numerous constraints. In the other, the community health workers were not allowed to use antibiotics. In this project there was a 54% reduction in neonatal mortality rate.  This can be a useful approach where referral of sick newborns and mothers is possible. The adoption of this approach can significantly improve breast feeding rates, and also contribute to exclusive breast feeding. It can also help to reduce deaths due to neonatal infections and prevent deaths and complications due to hypothermia. In both situations the neonatal mortality rates were high and the reductions in mortality were impressive.

Approach 3:  This approach uses a combination of home based and facility based post-natal care. In this approach, home visits are done according to an established schedule. Home visits are done by community health workers who live close to the family in the community. They are linked to facilities and are encouraged to refer cases who are sick. There are several advantages of this approach. Broadly it helps in early recognition of obstetric complications and life threatening neonatal problems for timely referral. It also helps to link the family to promote timely immunizations and child spacing services. 

Choice of approach to be adopted

The choice to be made regarding the approach to be used depends on the national policy, availability of resources, the local context, and a host of other factors. Irrespective of the choice of the approach adopted, the common denominator is the use of continuum of care between the hospital, the community and the family. In the hospital delivery, the key issues to be addressed relate to the provision of good quality care after child birth, monitoring during the stay in the hospital followed by discharge preparedness and smooth transitioning to home based care followed by home visits. In the case of home delivery, it comprises of an early home visit soon after birth followed by repeated home visits with provision for linkages between home and the hospital in case hospital care is required. In both situations, referral links are important. However, the common denominator is that post-natal care, its quality, equity and coverage are important in accelerating the reduction in maternal and neonatal mortality and in laying down a strong foundation for lifelong health. In developing countries, prominent equity issues to be addressed include transport delays and problems, out of pocket expenses, financial expenses and overcoming cultural and behavioral practices that adversely affect the care of the mother and newborn baby.

Causes of maternal and neonatal mortality- addressing the problem through post-natal care

Causes of maternal deaths and neonatal deaths are to be kept in mind in order to address these problems. Besides causes of death, the timing of death is also a very important consideration so that post-natal contacts can be timed strategically. This would help to address the preventable causes of mortality in the mother and newborn. In mothers, after child birth, excessive bleeding can kill her very rapidly. The situation becomes worse if the mother was already anemic before she bleeds. Therefore, monitoring of bleeding is very important. It is not easy to assess the quantity of blood loss. Besides assessment of quantity of blood loss, monitoring of pulse rate and assessment of early signs of shock become crucial. Timely recognition of excess bleeding and appropriate treatment can be lifesaving.  Sepsis in the mother is another serious and a common problem. Vigilance is required during post-natal monitoring to recognize signs of sepsis in the mother and treat it quickly and appropriately. Eclampsia as a cause of death in the post-natal period is relatively less common. It is estimated that about 20-25% of eclampsia occurs in the post-natal period,

In the new born, severe infections (sepsis), low birth weight, babies born with low gestational age (prematurity) or babies who are small for gestational age (fetal growth restriction) and birth asphyxia are major concerns. All of the above conditions are challenging. Infections are not easy to recognize early and these can progress rapidly and lead to serious complications or death if not treated early. Low birth weight, prematurity and fetal growth restriction require very good quality care and intense monitoring. Kangaroo mother care (KMC) is a key intervention recommended. Babies born with birth asphyxia require specialized care in hospitals with close follow up in cases that recover in the hospital. Besides the above conditions, other challenging conditions are babies born to HIV positive mothers and babies born with congenital anomalies.

The timing of post-natal care and equity

The timing of post-natal care after child birth is important. Maximum deaths in mothers and newborn babies occur during the first 7 days after child birth and amongst these the peak is within the first 3 days. Despite this knowledge, the post-natal visits are uncommon during this period of maximal risk. Even though, the number of post-natal visits may be adequate, the timing must be appropriate in order to contribute to reduction in preventable deaths. Only 42% women received post-natal care and only one third of them during the first 2 days after child birth and this is the period of maximal risk for the mother and the newborn baby. According to DLHS, only 44% of the mothers and newborn babies received post-natal visit during the first 48 hours after child birth. The number of post-natal visits was very low during the first week after child birth. A total of 55% received post-natal care from a private provider. Caesarian section deliveries received more post-natal contacts than normal deliveries. There were big differences in the post-natal care amongst different socio economic groups. The rich used the services three times more frequently than the poor. Amongst the well to do families post-natal visits were made in the private sector more often than in the government sector. The equity differences were less pronounced for antenatal care. In contrast, poor people had less post-natal contacts.   

Policy and strategy issues to be addressed

  1. Identifying the best channel of delivering postnatal home care based on cost effectiveness and sustainability;
  2. Establishing sick newborn care units, newborn stabilization units and newborn corners according to the category of hospital or health center;
  3. Consolidation of intensive care of sick mothers and newborn babies, outborn cases, and step down care
  4. Strengthening the health system to support health workers to deliver postnatal maternal and newborn services and care, including regular supplies, supervision and referral links;
  5. Recruiting, training and deploying health workers, including community level workers, to provide maternal and newborn care through postnatal home visits.
  6. Ensuring continued professional development and motivation of health workers, including community health workers;
  7. Assessing the current level and distribution of staff and their competencies to deliver the required services and care for mother and newborn survival. This can help in task shifting of roles and responsibilities;
  8. Developing recommendation on duration of hospitalization in low risk child birth and high risk child birth e.g. C-section, baby born with birth asphyxia, low birth weight, baby born to an HIV positive mother or baby with birth defect
  9. Providing home visits for maternal and newborn care in the first week of life to obtain smooth transitioning from hospital to home and providing lifesaving services in home deliveries;
  10. Where appropriate, adopting the strategy of providing home visits for newborn care in the first week of life by community health workers as a complementary strategy to facility-based and home-based care by skilled health workers. If necessary, policy, strategy, regulatory and legal framework for community health workers to provide postnatal care should be adjusted;
  11. Supporting communication efforts for community awareness and involvement in postnatal care.

Challenges

  1. Continued compartmentalization of services for mothers and newborns in the hospitals based on obstetrics and pediatrics.
  2. Lack of facilities for intensive obstetric care or pediatric care in the same hospitals with the result that the mother and the baby are separated
  3. Non availability of SOPs for monitoring of post-natal care in the hospital
  4. Low capacity of staff in rendering postnatal care
  5. Parental/family pressure about early discharge from the hospital
  6. Insufficient counselling facilities in the hospitals
  7. Lack of continuity from the hospital care to home based care
  8. Gaps in provision of care during referral
  9. Reluctance of the family to seek care when referral is advised because of cultural reasons
  10. Gaps in quality, equity and coverage of care

Opportunities

  1. Post-natal care provides a dual return for the investment since the problems and issues related to the mother and newborn are addressed in one contact;
  2. Post-natal period is unique since this is provides an opportunity for reduction of preventable mortality in the newborn and in the mother as well as reduce the chances of complications that can be life threatening;
  3. Parents and family are keen to get support and guidance since child birth is a moment of great joy for the family;
  4. Post-natal care provides a unique opportunity to lay the foundation for survival, nutrition and mental development for a productive and healthy future;
  5. This is a period when multiple preventive and promotive measures can be delivered to the family at an affordable cost;
  6. It is a unique opportunity to enlist family engagement in care of the mother and the newborn baby.

Key references

  1. The India country profile- countdown to 2015 countdown2015mnch.org/country -profiles/India Accessed December 2016.
  2. Miller YD, Dane AC and Thompson R. A call for better care: the impact of postnatal contact services on women’s parenting confidence and experiences of postnatal care in Queensland. Bio medical central Health services research 2014, 14, 635. http://creativecommons.org/licenses/by/4.0
  3. Erin Sines, Syed U, Wall S and Worley H. Postnatal Care: A Critical Opportunity to Save Mothers and Newborns. Population reference bureau 1-7, 2007
  4. Postnatal care for mothers and newborns Highlights from 2013 WHO guidelines. WHO, USAID, MCHIP and Maternal and Child Survival Program mcsprogram.org. Accessed December 2016
  5. PMNCH fact sheet: RMNCH continuum of care, reproductive maternal newborn and child health updated September 2011.
  6. Sitrin D, Guenther T, Murray J Pilgrim N, Rubayet S Ligowe R, Pun B, Malla H and Moran A. Reaching Mothers and Babies with Early Postnatal Home Visits: The Implementation Realities of Achieving High Coverage in Large-Scale Programs PLoS ONE 8(7): e68930. doi:10.1371/journal.pone.0068930. Accessed December 2016.

WHO- Recommendations on Postnatal Care of the Mother and Newborn. October 2013. Geneva: WHO

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