Routine postnatal/partum care: It is all about timing and contents Joseph de Graft-Johnson Team leader, Newborn and Community Health MCHIP October 9, 2009

2 Presentation Outline  Definition of postnatal/partum period  Causes and timing of maternal and neonatal deaths  Recommended schedule and contents for facility- based postpartum/natal visits  Recommended schedule and contents for home- based postnatal/partum visits  Discuss approaches for reaching mothers and newborns  Conclusion

Definition of postpartum period

4 Definition of postpartum/postnatal period  WHO:  Starts: one hour after delivery of the placenta  Ends: after 6 weeks Divided into: Immediate postpartum period:  First 4-6 hrs after delivery Late postpartum period:  6 hrs to 6 weeks

What are the major causes of maternal deaths – overall and during the postpartum period? When in the postpartum period do most of the deaths occur?

6 Causes of maternal deaths 31% - asia 34% - Africa

7 Causes of maternal death in postpartum period

8 Timing of postpartum maternal deaths Source: Li et al. 1996

What are the major causes of neonatal deaths? When do most of the deaths occur?

10 Causes of newborn deaths Source: Lawn JE, Cousens SN, Zupan J Lancet based on cause specific mortality data and estimates for 192 countries Indirect effects of preterm & small for gestational age?

11 Timing of newborn deaths Up to 50% of neonatal deaths are in the first 24 hours 75% of neonatal deaths are in the first week – 3 million deaths Source: Lawn JE et al Lancet 2005, Based on analysis of 47 DHS datasets ( ), 10,048 neonatal deaths)

What is the current recommended schedule for routine postpartum visits at health facilities?

13 Recommended facility-based postpartum/natal visits  Immediate PPC – provided before discharge  First visit: Within first week (preferably within 2-3 days)  Second visit: 4-6 weeks (Additional visits should be scheduled if woman/baby has a problem that is being managed on outpatient basis) WHO 2006

14 Coverage along the continuum of care The days of highest risk and lowest coverage * Immediate postnatal care is based on the DHS assumption that all facility births get PNC before discharge. Early postnatal care (within 2 days) at home was only measured for home births only in previous DHS Source: Opportunities for Africa’s Newborns, inputs from 28 African DHS from

15 PNC Coverage  47% of mothers and newborns do not receive skilled care during delivery (and those who do are send home early)  72% of all babies born outside health facilities do not receive any postnatal care

What is the primary purpose of routine postpartum care visits?

17 Primary purpose of PPC/PNC  Prevention: Ensure both mother and baby are in good health – and continue with healthy practices (thru counseling and observation)  Detection and management of problems before they become worse (thru good history, examination, laboratory tests and appropriate treatment)

18 Immediate postpartum care  Mother:  Monitor her every 15 minutes (measure BP & temperature, count pulse, observe breathing, vaginal bleeding, firmness of uterus, convulsions/unconsciousness)  Encourage her to pass urine  Encourage to eat, drink and rest  Newborn:  Monitor her every 15 minutes (breathing, temperature, pulse/heartbeat)  Initiate breastfeeding  Maintain warmth (skin-to-skin or wrapped)  Delay bathing  Polio 0 and BCG if feasible, ensure mother and baby has someone with them and they know when to call for help Ensure mother is counsel on postpartum care, hygiene, danger signs, birth spacing, nutrition, and both mother and baby re-examined before discharge and given a date to return

19 Content of 1 st and 2 nd Postpartum visit  Mother:  Ascertain general well-being (ask about presence of danger signs)  Check HIV status  Conduct physical exam (BP, temperature, pulse, palpate uterus, visual inspection of vulva and perineum, check pallor, exam breast)  Ask about birth spacing plans and current use of a FP method – counsel appropriately  Counsel on danger signs and prompt care-seeking  Counsel on nutrition and hygiene

20 Content of 1 st and 2 nd Postpartum visit…  Newborn:  Ascertain general well-being (feeding, ask about presence of danger signs)  If mother is HIV+ check if ARV has been given  Weigh baby  Conduct physical exam (count breaths, temperature, heartbeat,)  Observe breastfeeding – check positioning and latching  Counsel on exclusive BF, clean cord care, warmth maintenance  Counsel on danger signs and need for prompt care- seeking

21 Postpartum/postnatal home visits

22 Evidence of Home Visits for Newborn Care

23 Recommendation: underlying principles Core principle is the continuum of care covering both lifecycle and home-to-hospital (and “back again”) dimensions Home visit is a complementary strategy to facility- based postnatal care …. to improve newborn survival Facility births: assess health of mother and baby before discharge and give specific return date Non-facility births: Seek postnatal care from a skilled provider (in most places at facility) as soon as possible

24 Recommendation: Home visits  At least two home visits for all home births:  First visit within 24 hrs from birth  Second visit on day 3  Third visit on day 7 (if possible)  At least two home visits for all babies born in a health facility:  First visit as soon as possible when mother returns home  Second visit on day 3  Third visit on day 7 (if possible) NB: At least one home visit during antenatal period will be required

25 Recommendation: content of home visits  Ensure basic newborn care (or essential newborn care):  Early & exclusive breastfeeding  Maintenance of warmth  Hygienic cord and skin care  Caretaker’s handwashing  Assess for danger signs and refer  Counsel on danger signs and prompt care seeking  Identification and support for newborns with conditions that require additional care (e.g. LBW or sick baby, mother is HIV+)  Mother:  Ask and counsel about danger signs and prompt care seeking  Counsel on birth spacing and nutrition  Identification and support for mothers with conditions that require additional care? (use of Misoprostol tablets/oxytocin unject?)

26 Recommendation: LBW babies Additional care:  Increased attention to warmth through skin-to-skin  Assistance with breastfeeding, might include cup feeding  Extra attention to hygiene – particularly handwashing  Extra support for breastfeeding Will require an extra home visit (day 2 and 10)

27 Recommendation: Sick newborns  Families of sick newborns (possible neonatal sepsis) should be assisted to seek facility-based care. Care could be given on outpatient basis from a first level health facility if referral is not possible Use of community health workers to give antibiotic injections at home is acknowledged by WHO/UNICEF but not yet endorsed. Further evaluation of this intervention in routine settings for safety and sustainability is needed. Statement is silent on community-based management of asphyxia

28 Recommendation: Who should visit? Ideally these should be skilled health workers but…. Realistically:  Existing community health workers (paid and/or volunteers)  Health Surveillance Assistants in Malawi  Community midwives in Indonesia  Anganwadis and ASHAs in India  Female community health volunteers in Nepal  Health Extension Workers in Ethiopia  Create new CHWs (paid and/or unpaid) ESSENTIAL THAT CHWs HAVE THE KNOWLEDGE AND SKILLS TO ACCOMPLISH THEIR WELL DEFINED TASKS

29 Available materials SEARCH India UNICEF/ESAROPackage2006 Kintampo Ghana IMNCI India WHOPackage (under development) 2008 C-IMCI Bolivia WHO-UNICEFPackage CARING FOR THE NEWBORN AT HOME 2009 Adapted from WHO Others:ProjahnmoSNL/Ethiopia Gov. of Malawi Gov of Nepal

30 Job Aides  Counselling cards  Mother & Baby card  Referral note  CHW register Adopted from WHO

How can mothers and newborns be reached early at home to save their lives?

32 Conclusion  All mothers and newborns should receive appropriate care especially in the first hours and week of life when they are most vulnerable;  A household-to-hospital continuum of care including postnatal home care by community health workers is needed to save mothers and newborns  Both Facility and community health workers providing PPC/PPC should have the appropriate knowledge, skills and supplies to prevent, refer and/or provide initial/complete treatment for identified complications

33 Resources   Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice (WHO 2006)