Center for Development in Primary Health Care (CDPHC), Al Quds University

May 2003

This 35-page document shares results from a project that the United States Department for International Development (USAID) designed with the Palestinian Ministry of Health (MOH) and the Center for Development in Primary Health Care (CDPHC). The aim was to develop a service strategy to increase postpartum use of health care services by first-time mothers or women with one or two children in the West Bank and Gaza. Organisers were motivated by a concern about the lack of care provided to mothers and newborns during the perinatal period. For example, although 96% of mothers receive some antenatal care from a health professional, only one-quarter of mothers return for postpartum check-ups. In addition, survey data from the West Bank show that few mothers adopt family planning for spacing births during the postpartum period. The MOH estimates that pregnancy and maternity-related complications are the third leading cause of death among Palestinian women of reproductive age.

The report begins by describing the 28-month-long Pilot Health Project (PHP) of which the intervention evaluated here was one component; PHP on the whole involved efforts to upgrade antenatal and postpartum services in 27 primary health care clinics in 3 areas of the West Bank and Gaza. In addition, PHP sought to collect data on the population and special topics which would assist in developing better health strategies and improve the evaluation of the PHP. The PHP basic service delivery model includes home visits by a community health worker (CHW) to recently delivered women 2-3 days after delivery. The study intervention, which is the focus of this report, involved adding a second home visit to consenting women of low parity 30-38 days after delivery by the same CHW who conducted the first visit. During the second home visit the CHW reminded the women about their day 40 clinic visit for postpartum care and highlighted the importance and benefits of that visit. The CHW also provided counseling and health education specific to low parity women and their husbands (if available) relating to maternal and child health, contraception, and breast and cervical cancer awareness and prevention. CHWs received training on how to provide counseling and services that are tailored to the needs of low parity women.

A total of 257 women completed the study (112 in the control group and 145 in the intervention group). As detailed here, the study results showed that the second home visit by the CHW was associated with a substantial increase in the likelihood of visiting the maternal and child health (MCH) clinic on day 40 (49.1% of intervention group mothers versus 35.6% of control group mothers, p<0.05). The second visit was also associated with increased support provided by the husband, namely by encouraging the mother to visit the clinic on day 40 (51.0% of intervention group husbands versus 29.0% of control group husbands, p<0.05), as well as increased likelihood of husband-wife communication about timing of next pregnancy (86.0% of intervention group couples discussed timing of next pregnancy versus 77.0% of control group couples, p<0.05). While husbands of intervention group mothers were more likely to encourage their wives to make the day 40 visit and more likely to discuss the timing of the next pregnancy with their wives compared with those in the control group, husbands in the control group were more likely to want a birth interval of 3 or more years (56.7% versus 25.8%, p<0.001). Moreover, the intervention was not associated with improved knowledge or practices of low parity mothers regarding their own health or that of the newborn. Similarly, the intervention was not associated with increased use of family planning methods, improved knowledge, or more positive attitudes towards family planning.

The authors explain that a number of factors may have undermined the impact of the intervention on mothers' knowledge and practices. First, as a result of the deteriorating political conditions in the study sites, it is likely that the intervention was not properly implemented by some of the participating clinics. Further, frequent checkpoints and the siege imposed by the Israeli army often interfered with the CHWs' ability to conduct home visits. In addition, due to the prevailing political conditions, some participating non-governmental organisations (NGOs) may have given higher priority to emergency services than to postpartum services. These conditions may have also interfered with proper monitoring and supervision of CHWs' performance during the second home visit. Finally, "It is noteworthy that very few husbands were present during the CHW visits, which were probably conducted in the morning when husbands were at work. Involving men is considered crucial to improving the reproductive health of women."

Reflecting on the findings, the authors provide the following recommendations:

• At least one visit should be made to low parity women during the postpartum period.
• Performance of CHWs during home visits, especially with regard to information exchange, needs improvement through proper monitoring, supervision and continuous training.
• Efforts should be made to involve the husbands of low parity women through changing the time of the visit to the afternoons and/or through providing written materials to the woman so she can share them with her husband.
• The CHW should encourage mothers to request postpartum services during clinic visits, even if they do not have any postpartum warning signs.
• Services provided during the day 40 visit should cater to the needs of the mother as well as the newborn.
• Use of mass media, especially television, as a means for disseminating health information to low parity mothers should be investigated - Media messages should encourage women to seek postpartum care and should educate couples to space their births for the health benefits to both the mother and the child. Health hazards associated with closely spaced pregnancies should also be stressed. However, the content of the messages and the timing of the broadcast should be carefully selected in order to avoid undue embarrassment to couples in the presence of their children.
• Research is needed to study the knowledge and attitudes of low parity couples towards birth spacing and use of contraception.

Click here to access a related peer-reviewed summary on the Health e Communication website, and to participate in peer review.