Professional Documents
Culture Documents
1093/intqhc/mzp050
Advance Access Publication: 28 November 2009
Abstract
Objective. To assess changes in the quality of care following the introduction of a new postnatal package.
Design. Using a pre-test, post test design to observe client – provider interactions with women 0 – 6 weeks postpartum.
Setting. Four health facilities in a rural district, eastern Kenya.
Participants. Health providers and postpartum women.
Intervention. Introduction of comprehensive postnatal package of care, with three targeted assessments within 48 h of
birth, 1 – 2 weeks and 6 weeks, to providers working in maternity and maternal and child health clinics.
Main outcome measure. Improved quality of postnatal counselling.
Results. Increased mean scores for counselling on danger signs in the newborn (0.24 – 1.39) and infant feeding (1.33 –
2.19) were noted. The total quality of care index for the newborn increased overall but remained lower than desired
(from 3.37 to 6.45 out of 11). Essential maternal care index improved (3.4 – 8.72 out of 23). More women accepted a
family planning method at 6 weeks (35 – 63%).
Conclusions. The introduction of new comprehensive postnatal care package improved performance of providers in counsel-
ling in maternal and newborn complications, infant feeding and family planning. Additional studies looking at the postpartum
family planning needs for women living with HIV would also be useful. However, providers would benefit from additional
clinical skills for managing maternal and newborn complications during the critical period following childbirth.
Keywords: comprehensive postnatal care, maternal, newborn, Kenya
Introduction both maternal and newborn deaths are most likely [2, 3]. In
Africa alone at least 125 000 women and 870 000 newborns
The postnatal period is neglected throughout Africa. The die in the first week after birth every year [4]. For many
quality of care for those who seek services is often poor women in eastern and southern Africa, the postnatal period is
and many women and their infants are not encouraged to a time of increased susceptibility to HIV and STIs [5, 6].
seek care until 6 weeks after delivery. Lack of a defined Although HIV infection in the mother will influence the
postnatal care package contributes to the discontinuity baby’s survival, practically all neonatal deaths in the first
between maternal and child health programs [1]. month of life are due to non-HIV causes (e.g. asphyxia, sepsis
Although there have been improvements in the quality of and prematurity), highlighting the need to address the quality
care during pregnancy and childbirth, there is limited uptake of basic maternal and newborn care.
of early postnatal services for mother and newborn and Evidence suggests that there are some ‘crucial’ moments
acceptance and use of postpartum family planning methods in when contact with the formal health system during the post-
many countries. The greatest gap in the continuum of care partum period by skilled attendants could be instrumental in
occurs during the first crucial week after childbirth when identifying and responding to needs and complications after
childbirth: the first few hours after birth (whether at home care before (September 2006) and after (July 2007) the
or in a health facility), between 3 and 7 days and at 6 intro-duction of the new postnatal care package. The four
weeks [7, 8]. Better understanding of complications such health facilities in Embu district, Eastern Province, Kenya
as haem-orrhage in the early postpartum period, which is were pur-posefully selected according to specific criteria
greater than 30% in Africa and Asia [9], has shown the
which included the provision of: focused antenatal care,
importance of early and universal postpartum care [10].
The family planning needs of women during the first year
PMTCT, family planning and counselling and support for
postpartum are also not well addressed [11, 12]. In Kenya, infant
68% of women have an unmet need by 12 months [13, 14]. feeding.
Postpartum women need information and services, provided Direct observation of client – provider interactions were
at appropriate times, to address this unmet need. Providing a used to measure quality of postnatal care. The 48 h and
continuity of care from antenatal services, including preven- 2 weeks consultations were not routine prior to the interven-
tion of mother-to-child transmission (PMTCT) of HIV, deliv- tion and so none was observed pre-intervention. The 6-week
ery and postpartum care can ensure that women’s health and routine consultations were observed both before and after the
fertility intentions are more likely to be effectively met [15]. intervention. Observations of the cross-sectional client –
To improve the quality of postnatal care, the Ministry of provider interactions were carried out concurrently in mater-
Health (MOH) in Kenya increased both the recommended nity and maternal and child health/ family planning units
timing and content of postnatal services a women and her during the same time period with cross-sectional samples
infant should receive to at least three assessments within the of
first 6 weeks after childbirth (within 48 h, 1 – 2 weeks and at women for each category at 48 h ( post-intervention only:
6 weeks. The study assessed whether the introduction of post- n ¼ 29), 1 – 2 weeks ( post-intervention only: n ¼ 64) and
natal package of care contributes to improved counselling on 6 weeks ( pre-intervention: n ¼ 86 and post-intervention:
essential maternal and newborn health and family planning. n ¼ 70). All women attending for postnatal services during
the data collection period were approached and requested
for permission to observe their consultation. Data
Methods collectors were qualified midwives from outside the study
district, trained for 5 days and included role playing to
Intervention description internalize the data collection instruments. Supervisors
checked all com-pleted instruments for data quality and
The new Kenya comprehensive postnatal care package and accuracy prior to data entry and analysis.
job aid (checklist to aid providers) were developed by the Data were entered using Epidata and exported to SPSS
Division of Reproductive Health (DRH), MOH, ACCESS- for analysis. The indicator/summary scores were obtained
FP/Jhpiego and FRONTIERS/Population Council. These as the additive sum of items/variables representing specific
tools aim to increase provider awareness of the need to aspects of postnatal care (e.g. essential newborn care and
focus on providing the continuum of care from pregnancy essential maternal care including return to fertility and
to labour and childbirth and through to the post-natal family planning) observed during consultations with the
period to ensure both mother and newborn survive. Table 1 clients. Distinct variables and indicator scores were tested
summarizes the content of the postnatal care package using Wilcoxon – Mann – Witney test to determine the
which incorporates relevant maternal and newborn significance of differences between the pre- and post-
healthcare services in the postnatal period as well as intervention results at 6 weeks; this was after confirming
postpar-tum family planning. that the normality assumption of the two-independent
To introduce the postnatal care package, a 3 day training samples t-test failed. A P-value of less than or equal to
took place for staff and their supervisors from the maternal 0.05 was used as the threshold for significance. This
and child health clinics and maternity units from four health method was used to demon-strate overall improvements in
facilities in one district. Initially, 24 providers from the quality of care rather than individual aspects of care.
selected facilities were oriented in the postnatal care package,
as well as in the use of a new postnatal register recently
released by the MOH. Subsequently, the MOH requested a
further 52 providers to be trained from other health facilities Results
in the district. Regular supportive supervision visits were
made to the four health facilities to assess knowledge, appli- The quality of care was assessed on the basis of
cation of that knowledge and skills learned, and to resolve counselling for essential newborn and maternal health.
gaps identified during the visit. Tables 2 and 3 outline the detail of the key indicators used
for compiling the composite scores for newborn and
maternal care, respectively.
Study design
A pre – post intervention cross-sectional design was used to
assess any changes in the quality of counselling for postnatal Newborn care
The four key indicators making up essential newborn care
include asking about danger signs in the newborn, counsel-
ling on danger signs in the newborn specific to the early
25
Warren et al.
Table 1 Timing and content of the new postnatal-family planning package of care in Kenya
Timing of assessment or visit Services for the mother Services for the baby
.............................................................................................................................................................................
birth, and to counsel women on potential signs of compli- Among women counselled on family planning, two or
cations. These included bleeding since birth, colour/smell of more methods were discussed in three quarters of the 48 h
vaginal discharge, condition of perineum/caesarean section consultations and in two-thirds of the 2 and 6 weeks consul-
scar, signs of thrombophlebitis. For the majority of consul- tations. The majority of women (n ¼ 64) chose a family
tations within 48 h and 2 weeks of delivery, women were planning method (83%) during the 2 week consultation. There
asked about any bleeding since birth, the colour and smell of was a significant increase from 35% (n ¼ 86) to 63% (n ¼
their lochia, although few asked about the condition of the 70) where women were observed choosing a family planning
perineum or signs of thrombosis (Table 3). method at 6 weeks. After the intervention, the lower level of
Most providers were observed counselling or giving family planning uptake during the 6 week visit than the 2
mess-ages to the mother at 48 h on the possible danger week visit (63 vs. 84%) is probably because many women
signs: excessive bleeding, foul smelling vaginal discharge attending the 6 weeks consultation had already received a
and poor healing of perineum. During the consultations on family planning method before leaving the health facility after
the post-natal ward, all women had their blood pressure birth or during the 2 weeks visit. At the 2 weeks
taken, four-fifths their temperature taken, but only one- consultations, only 16% of the women observed were not
third had their pulse measured. All postpartum women using any form of family planning. Two-thirds of those prac-
were palpated for uterine involution and virtually all were ticing family planning at 2 weeks were using the lactational
given a full physical examination. amenorrhea method (LAM), although few (4%) used a
In less than one-fifth of the consultations within 48 h were condom as well as LAM. Other methods used at 2 weeks
risk factors on prevention of sexually transmitted infec-tions included implants (4%), vasectomy (2%) and condoms (4%).
including HIV and condom use discussed, although providers Table 4 compares the mean summary of quality of care for
did discuss the importance of partners counselling and testing mothers and infants observed at 6 weeks both before and after
for HIV during most of the consultations. At the 2 weeks the intervention. Overall, the total quality of care score
consultations, providers were not likely to counsel on doubled. The improvements in all aspects of quality of care
sexually transmitted infections/HIV risks, but some are highly encouraging, but given the poor level of care found
improvements were observed following the intervention at the during the pre-intervention assessments the composite score
6 weeks consultations (Table 3). after the intervention still falls short of the level desired.
27
28
Warren et al.
Table 3 Maternal indices in postnatal clinic
Table 4 Comparison of mean summary quality of care scores for maternal and infant health observed during the 6 weeks
consultations
Maternal health
Asking about danger signs since childbirth (0 – 4)** 0.34 1.11
Physical examination conducted (0 – 7)** 1.88 3.79
Counselling on HIV/STIs* (0 – 8) 0.51 1.15
Family planning (0 – 4)** 0.53 1.7
Total quality of care index for postpartum woman (0 – 23)** 3.26 8.27
Infant health
Counselling on possible danger signs (0 – 3)** 0.24 1.39
Counselling on infant feeding (0 – 3)** 1.33 2.19
Immunizations received (0 – 2)** 1.25 1.76
Total quality of care index for newborn (0 – 11)** 3.37 6.45
community midwives, and community health workers [18] 3. Lawn JE, Cousens S, Zupan J. Neonatal Survival 1: 4 million
is also crucial. neonatal deaths: When? Where? Why? Lancet 2005;365: 891
Although the health facilities are typical of those found – 900.
across Kenya, this study had some limitations. The contra- 4. Warren C, Daly P, Toure´ L et al. Postnatal care. In: Lawn J,
ceptive prevalence rate in Eastern Province is 51% (with Kerber K eds, Opportunities for Africa’s Newborns, Cape
use of modern methods at 38%), which is higher than the Town, South Africa: Partnership for Maternal, Newborn and
national rate of 39% (modern methods 32%) [13]. The Child Health, 2006.
client – provider observations of postnatal care – family 5. McIntyre J. Maternal health and HIV. Reproductive Health
plan-ning services for 48 h were only recorded at the Matters 2005;13:129 – 35.
maternity unit for the post-intervention group.
6. Department of Health, South Africa. National Committee on
Observations of ser-vices for the 2, 6 weeks and 6 months Confidential Enquiries into Maternal Deaths. Saving Mothers
visits included clients that delivered at home who might 1999-2001, Pretoria, South Africa: DOH, 2003.
have different needs or characteristics to women who
delivered at the hospital. 7. Lawn JE, Cousens S, Zupan J. Neonatal Survival 1: 4 million
neonatal deaths: When? Where? Why? Neonatal Series,
The introduction of new comprehensive postnatal care
Lancet, London, 2005. 9 – 18. UK.
package improved performance of providers in counselling in
maternal and newborn complications, infant feeding and 8. Narayanan I, Cordero RD, Faillace S et al. The Components of
family planning. However because this is a generally neg- Essential Newborn Care. Basics Support for
lected area, providers would benefit from additional clinical Institutionalizing Child Survival Project (BASICS II),
skills for managing maternal and newborn complications Arlington, VA, USA: USAID, 2004.
during the critical period following childbirth. 9. Khan KS, Wojdyla D, Say L et al. WHO analysis of causes of
maternal death: a systematic review. Lancet 2006;367:1066 – 74.
10. Fort A, Kothari M, Abderrahim N. Postpartum care: levels
Acknowledgements and determinants in developing countries. Calverton, MD,
USA: Macro International Inc., 2006.
The study would not have been possible without the
11. Ross J, Winfrey W. Contraceptive use, Intention to Use and
support of the Annie Gatito and Mary Githitu of the Unmet Need During the Extended Postpartum Period. Int Fa
Division of Reproductive Health, Ministry of Public Plan Perspect 2001;27:20 – 7.
Health and Sanitation. We also acknowledge all women
who gave us their time for the study. Special thanks go to 12. Fort A, Kothari M, Abderrahim N. Postnatal care: levels and
Ian Askew of Population Council and Cat McKaig and determinants in developing countries. Calverton, MD, USA:
Macro International Inc., 2006.
Holly Blanchard of ACCESS-FP for their thorough review
of earlier drafts. 13. Central Bureau of Statistics, Ministry of Health and ORC
Macro. Kenya Demographic and Health Survey 2003.
Calverton, Maryland: CBS, MOH and ORC Macro, 2004.
Funding 14. Borda M. ‘Family Planning Needs during the First Year
Postpartum’, Unpublished paper. ACCESS-FP Project,
This study was made possible by the generous support of Baltimore, USA: Jhpiego, 2006.
the American people through the United States Agency for 15. Warren C, Ts’ukulu T, Semakaleng P et al. Extending prevention of
International Development (USAID) under the terms of mother-to-child transmission through postpartum family planning in
Cooperative Agreement Number HRN-A-00-98-00012-00 Lesotho. Frontiers in Reproductive Health Program, Final Report,
and Subproject number 5800 53108. The contents are the Washington, DC: Population Council, 2008.
responsibility of the authors and do not necessarily reflect
16. Warren C, Shongwe R, Waligo A et al. Repositioning postnatal
the views of USAID or the United States Government.
care in a high HIV environment Swaziland. Horizons Final
Report, Washington, DC: Population Council, 2008.