Frontiers in Reproductive Health, Population Council (Mwangi, Warren); ACCESS-FP, Jhpiego (Koskei, Blanchard)
This 48-page report describes and assesses an initiative to develop and introduce a strengthened postnatal care (PNC) package into one hospital and 4 health centres in Embu district, Eastern Province, Kenya. Two United States Agency for International Development (USAID)-funded projects - the Population Council's FRONTIERS project and Jhpiego's ACCESS–FP project - formed a partnership to support Kenya's Department of Reproductive Health (DRH) in its efforts to document the feasibility, acceptability, and quality of care of the endeavour to increase both the recommended timing and content of postnatal services a women and her infant should receive to at least 3 assessments within the first 6 weeks after childbirth. This orientation package, which was introduced and evaluated between 2006 and 2008, also provided opportunities to deliver appropriate family planning (FP) advice and methods at several points in time.
As detailed here, the PNC-FP package incorporated relevant maternal and newborn health care services in the postnatal period with a specific focus on postpartum FP. Job aids were also produced. The 3-day orientation training included staff from the participating health facilities, as well as provincial and district reproductive health (RH) trainers/supervisors. In total, 73 health care providers were oriented in the PNC–FP package, as well as in the use of a postnatal register released by the Ministry of Health (MOH). Regular supportive supervision visits were made during the intervention period to reinforce application of the package.
The study used a pre-post intervention design. For the quality of care assessment, data were collected through interviews with health care providers, structured observations of client–provider interactions during the postnatal consultations and a facility inventory. Postpartum women were recruited and interviewed following childbirth on the postnatal ward in Embu Provincial General Hospital and interviewed again in their community after 6 months.
Selected key findings from the report include:
- Providers' knowledge - Examples:
- After the intervention, more nurses reported having ever received training in PNC, increasing from 35% to 80%.
- The orientation package touched only briefly on complications in the postnatal period. There were limited and non-significant improvements in providers' knowledge on signs of postpartum hemorrhage (PPH). However, knowledge of essential actions for managing PPH showed significant improvement, from a mean score of 1.9 to 2.6 out of 4. Knowledge on all signs of puerperal sepsis improved (although none of them significantly) after the training, with the composite score increasing from 1.88 to 2.53 out of a possible 5.
- There were significant improvements in provider knowledge of counselling and support for care of the infant after birth and before discharge from the hospital; for example, in observing proper feeding before discharge (28% vs. 80%) and proper attachment and positioning of the breastfeeding baby (22% vs. 51%). There were non-significant increases in knowledge of management of low-birth weight infants; however, level of knowledge remains at about half of what is expected (6.4 out of 10).
- Provider recall of the key maternal and newborn health messages for counselling women during the first week postpartum stayed relatively high (averaging 64%), but there were few statistically significant changes after the training (apart from knowledge of danger signs in mother and baby, which increased significantly from 15% to 40%).
- Before the intervention, 6 weeks had clearly been seen as the most appropriate time to start discussing FP; due to the intervention, "there was a remarkable increase in providers indicating that they would offer women any FP method at the 48 hours and two week consultations".
- Overall quality of care - Examples:
- Comparisons of the quality of care provided at 6 weeks between the pre- and post-intervention groups found that, overall, the total score tripled. However, "given the poor level of care found during the pre-intervention assessments the composite score after the intervention (8.72 out of 25) still falls short of the level desired".
- Comparisons between the pre- and post-intervention groups at the 6 week consultation showed significant increases after the intervention for counselling on difficulty with feeding (12% to 50%), difficulty with breathing (5% to 39%), and whether the baby felt hot or cold (8% to 50%). "Once again, while providers' performance was significantly improved by the training, the overall quality of care provided started and remains weak."
- After the intervention, provision of infant feeding advice during the 6-week consultation increased significantly, from 59% to 97% of consultations, and the proportion of consultations in which providers were observed requesting mothers to demonstrate feeding practices also increased significantly from 10% to 46%. At 6 months postpartum, women were asked to recall if any providers had recommended anything about breastfeeding. Before the intervention, 48% mentioned that exclusive breastfeeding had been recommended; this increased significantly to 70% after the intervention.
- Comparisons of the quality of fertility and FP counselling during the 6-week consultations found that the intervention "led to dramatic improvements in all of the indicators, with over two thirds of women being advised about return to fertility and at least two methods, and over 80 percent of women being asked about and receiving their preferred method."
- A composite score was calculated for observations of client-provider rapport at 48 hours using 9 indicators. Out of a possible score of 9, the mean score was 8.97, indicating very high levels of rapport; at the 2-week consultations, rapport scores remained high, with a mean score of 7.78.
- Knowledge of return to fertility, and uptake of FP postpartum - Examples:
- The intervention did not have an effect on women's awareness of when they might be able to conceive following childbirth; this awareness remained very low at 15% in the pre-intervention group and 9% in the post-intervention group.
- Most women interviewed on the postnatal ward within 48 hours said that they intended to use FP during the subsequent 12 months; significantly more women made this statement after than before the intervention (84% vs. 68%). Also, significantly more women were observed accepting an FP method during the 6-week consultation after the intervention (specifically, the intrauterine device (IUD) and the lactational amenorrhoea method, or LAM).
- Although there was no difference in overall use of FP between the 2 groups at 6 months, there were significant differences in the timing of starting to use an FP method: Before the intervention, only 6% of women had started using FP by 2 months, whereas this had increased to 62% of women in the post-intervention group.
- Fewer women after the intervention had an unmet need for FP.
- Postnatal clinic attendance: After the intervention, significantly more women and their infants attended postnatal clinics earlier and more frequently in the 6 months following childbirth, and significantly more women had completed the 3rd Pentavalent vaccination for their infants (98% vs. 90%). Twice as many infants received postnatal care than their mothers, probably because the immunisation schedule is fairly well established in Embu district.
- Infant mortality: Only 1 woman in the post-intervention group lost an infant, compared with 9 in the pre-intervention group, which may be attributable to the additional assessments and counseling given at 48 hours and 14 days, prompting women to return should they suspect danger signs for their infants.
The authors conclude by recommending that, to raise the standard of care still further, the PNC-FP training package would benefit from having a clinical skills component for managing maternal and neonatal complications. Also, they propose including key actors in consultations designed to provide the opportunity for engaging with pre-service training institutions and professional bodies to ensure institutionalisation and standardisation of the PNC-FP training approach. This includes integration or linkages with prevention of mother-to-child transmission (PMTCT) of HIV, and sexually transmitted infection (STI) services and incorporating or updating curricula of pre-service training institutions and professional bodies. They also recommend strengthening community linkages to continue the momentum towards creating awareness about the new the postnatal consultations and services; there is a need to involve critical actors, such as male partners and mothers-in-law, community leaders and health committees, community midwives, and community health workers.
Email from Angela Nash-Mercado of Jhpiego, forwarded by Sandra Kalscheur to The Communication Initiative on August 14 2008; and email from Charlotte Warren to The Communication Initiative on August 20 2008.