Routine postnatal/partum care: It is all about timing and

contents

Joseph de Graft-JohnsonTeam leader, Newborn and Community HealthMCHIP 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

Hemorrhage, 50.20%

Infection, 29.90%

PIH, 12.90%

Other, 7%

8

Timing of postpartum maternal deaths

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Day 1 Days 2-7 Days 8-14 Days 15-21

Days 22-42

Number of days

Pe

rce

nta

ge

of

de

ath

s

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 2005. 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 (1995-2003), 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

69

42 37

830

65

0

25

50

75

100

Antenatal care(at least one

visit)

Skilledattendant at

birth

ImmediatePostnatal

Early postnatal(w ithin 2 days)

Exclusivebreastfeeding

<6 months

3 doses ofDPT

vaccination

Co

vera

ge

(%)

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 1998-2005

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 1st and 2nd 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 1st and 2nd 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 survivalFacility births: assess health of mother and baby

before discharge and give specific return dateNon-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/ESAROUNICEF/ESAROPackagePackage

20062006

KintampoGhana

IMNCIIndia

WHOWHOPackage Package

(under development)(under development)

20082008

C-IMCIBolivia

WHO-UNICEFWHO-UNICEFPackagePackage

CARING FOR THE CARING FOR THE NEWBORN AT HOMENEWBORN AT HOME

20092009

Adapted from WHO

Others: Others: ProjahnmoProjahnmo

SNL/EthiopiaSNL/EthiopiaGov. of MalawiGov. of MalawiGov of NepalGov 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

www.globalhealthlearning.org/login.cfm Pregnancy, Childbirth, Postpartum and

Newborn Care: A guide for essential practice(WHO 2006)