Integration of postnatal care with PMTCT: Experiences from Swaziland Indira Narayanan, MD, Consultant, MNCH Goldy Mazia, MD, MPH, Technical Officer, Newborn Health Maternal and Child Health Integrated Program (MCHIP) Global Maternal Health Conference Habitat Center, New Delhi, India (August 30 – September 1 , 2009)

The Maternal and Child Health Integrated Program (MCHIP) USAID Bureau for Global Health’s flagship maternal, newborn and child health program Working in well over 30 countries worldwide MCHIP supports programming & opportunities for integration in: Maternal, Newborn and Child Health Immunization, Family Planning, Malaria, HIV/AIDS Wat/San, Urban Health, Health Systems Strengthening 2

Introduction In high HIV prevalence settings PMTCT programs link with existing MNH services assuming that the quality of care is adequate; but In many developing countries routine MNH care is inadequate, especially related to newborn health and early postpartum/postnatal care of the mother and baby Conventional PNC starts between 4-6 weeks after delivery Most maternal and neonatal deaths occur within the first 72 hours postpartum Maternal and newborn deaths due to other causes are generally more common than those due to HIV and AIDS, and many can be prevented with appropriate care Inadequate quality of care at facilities, inappropriate organization of services and poor behaviors of health workers continue to present challenges

Background HIV prevalence is very high in Swaziland: 26% in women of reproductive age (DHS ’06), and 39% in antenatal clinics (MOH PMTCT survey ’06) EGPAF with various partners was already well focused on PMTCT services which had scaled up since 2003 BUT there was poor follow-up for HIV care and treatment after delivery and inadequate focus on maternal and newborn care, especially in the early postnatal period. The existing MOH policy recommended the first postnatal visit at 6 weeks (mainly for FP and immunizations) In response to poor and delayed postpartum follow up, the MOH expressed interest in changing the postnatal care guidelines to ensure early coverage for mother and baby

Interventions Objectives of intervention - to improve, based on MOH requirements: Quality of facility based postnatal care linked with PMTCT Utilization of post-natal services early in the 1st week Utilization of HIV/AIDS care and support services Main focus was on the most neglected areas: Selected aspects of maternal health such as proper assessment before discharge and during postnatal visits; care of the newborn, and FP utilization Sites covered : 3 hospitals and 4 health centers in the 2 most populated regions (~18,000 deliveries/year) Timeframe: February ’06 to April ’07 Facility-based operations research with pre- and post- evaluation Components of Intervention: (a.) Capacity building of trainers/supervisors and health providers, (b.) Activities to facilitate organizational changes and (c.) Supportive supervision and M&E Mention midwifery schools trainers. BASICS felt that it was very important to start the link with the community, hence, the meeting with the trainers of CHW

Interventions: A. Capacity Building Modified cascade approach used to promote continuity & quality Quality care at key times in postpartum care, integrating MNH components (assessment, care and counseling) and FP with existing elements of HIV/ AIDS prevention, care and treatment 132 staff trained : (i) core group of trainers/supervisors, midwives and nurses, (ii) physicians - orientation sessions (iii) national CHW trainers Selected components: Immediate essential MNH care (within the first 6 hours of delivery) Pre-discharge care (including providing appointment for 1st visit) Early postnatal visit (within 1 week as recommended by MOH - BASICS advocated for visit within 3 days) Subsequent PN visits during next 4- 6 weeks (earlier as required) In the core group we had trainers from all 3 nursing schools (midwifery department)

Interventions: Continued B. Organizational Changes Physical space (room) and basic equipment/supplies Appropriate allocation and limiting rotation of staff Improved client flow - shorter waiting time and various services provided in one place by one person to both mother and baby at the same time C. Supportive Supervision and M & E Baseline and end line evaluations by Horizons/Population Council: Health providers interviews, observations of client-provider interactions, postpartum women exit interviews Findings from on-going monitoring during monthly supportive supervisory visits facilitated by BASICS

Supportive Supervision : Findings Baseline not established, but many of these services were not provided prior to the intervention. Adequate training was also limited prior to intervention. Generally the observations showed no increasing trend over time, with good results seen immediately after training and retained through entire period of observations, as evidenced by narrow confidence intervals despite small sample sizes. The encounter with the worst performance, care of the mother immediately after delivery, was not an important part of the project and training on this was minimal. But this reinforces the effect of program training, as those encounters that received more program attention also showed better performance by providers. Weak performance in Immediate Care of the Newborn was caused primarily by not preparing the room or reviewing records appropriately, and by not advising mother to avoid applying traditional medications to the cord. Weak performance during Care of the Mother Immediately after Delivery was due to the provider not taking vital signs, not encouraging mother to pass urine before transfer to PN ward, and not retaining mother in labor ward for at least 1 hour. Weak performance during Care of the Mother during Pre-Discharge was primarily to providers not checking the mothers’ records appropriately. 8

Cotrimoxazole Prophylaxis (Interviews of Mothers) 9

Utilization of Services: Increase in early postpartum visits Includes 2nd visits 10

Examination of the postpartum woman 11

Lessons Learned PMTCT programs have tended to be vertical, and while linking with MNCH programs, have not considered or contributed to their quality. It is feasible and beneficial to integrate RMNCH into PMTCT programs and improve quality of care and have access to their concomitant resources. The mother and baby dyad can be assessed and managed together. The first week, especially the first three days, should be covered as a priority in the most feasible and effective manner at both facility and community levels with links between the two.

Integration of PMTCT and Care/Treatment with Quality RMNCH Essential Universally PMTCT programs can safe guard their investment by ensuring that mothers and babies: Receive quality routine and HIV care, treatment, prevention and counseling Avoid getting ill and dying of other more common causes in the early postpartum period This integration also increases the platform for PMTCT and prevention of HIV/AIDS Source: WHO (BBC) Source: Senegal Basics Office