Experts from the World Health Organization (WHO) and Ministries of Health of Sri Lanka, Rwanda and Ethiopia gathered yesterday to discuss an often forgotten part of the maternal and neonatal health continuum: postnatal care (PNC), which is critical to both the health of the mother and newborn. Even when progress is seen in facility care and skilled birth attendance (SBA), PNC lacks behind and has the lowest coverage of any care type along the continuum. In the Democratic Republic of Congo, only 35% of mothers receive PNC, while 93% have SBA, said Etienne Langlois of WHO.
With the majority of deaths for women and newborns happening after birth and within the first month of life, standards for PNC reflected in policy and practice are crucial. The new postnatal guidelines released by the WHO this month will hopefully serve as a catalyst to amplify efforts for PNC.
Bernadette Daelmans, coordinator of policy, planning and programmes in the department of maternal, newborn, child and adolescent health at WHO, presented the process adopted to create the evidence-based guidelines and what changes have been made since the last iteration. So what is new about the guidelines? It is now recommended that women should receive facility care for at least 24 hours after birth, an increase from the previously recommended 12 hours. In addition, there should be at least three PNC visits. The timing of these visits, on day 3, between 7-14 days and six weeks after birth, are selected for the unique impact they can have on mortality and morbidity.
Another large change to the PNC guidelines is in regards to neonatal skin care. For years, studies have shown that chlorhexidine used for umbilical cord care after birth can decrease neonatal infections and death. Now, WHO has a guideline and recommendation for this practice. Women who give birth at home in areas with a neonatal mortality rate greater than or equal to 30 neonatal deaths per 1000 live births, should apply chlorhexidine daily to the umbilical cord for the first week of life. For newborns born in health facilities or where the NMR is low, clean, dry cord care is recommended, with chlorhexidine used where traditional, yet harmful substances are used on the cord.
But what does this mean for countries? How can they implement these changes in a context specific way? WHO recommends creating a continuum between facility and home, ensuring adequate infrastructure so providers can provide care respectfully and implementing the baby-friendly hospital initiative. Though this sounds straightforward enough, country experts reveal the challenges around implementing PNC and these new guidelines.
Currently, PNC has some of the greatest inequities, with coverage currently favoring urban settings. What does this mean and how can we address these inequities? Community-level interventions are needed but “we also need health systems that deliver quality PNC services. We need to strengthen delivery at health system level,” said Langlois.
Kapila Jayaratne, national programme manager in the family health bureau at the Ministry of Health in Sri Lanka, noted that sufficient human resources are often a problem in reaching women and newborns with PNC. Catherine Mugeni of the Ministry of Health in Rwanda echoed the issue of human resources. Turnover of staff is high and even where numbers of health workers are sufficient, keeping them properly trained and updated is difficult.
Part of this problem may be that often community health workers who serve on a volunteer basis don’t have the resource or renumeration they need in order to provide sufficient and quality care. Lisanu Taddesse of the Ministry of Health in Ethiopia, noted a solution to this problem in the structure of Ethiopia’s Health Extension Worker (HEW) Program where HEWs are government employees. This improves regulation and supervision, he argued.
Taddesse summarized the successes they’ve had in increasing both facility birth and PNC in Ethiopia, but also the challenges. Where neonatal and infant mortality are high, women and families don’t consider the newborn a full human being for the first days or months of life. This coupled with cultural practices of maternal isolation after birth are barriers to seeking postnatal care where home visits are not possible.
As Jayaratne, Taddesse and Mugeni summarized their current approach and considerations for context specific implementation, Langlois issued a reminder. “When the PNC guidelines are implemented at the country level, adaptability can’t inhibit fidelity,” he said. Robert McPherson an independent consultant at Save the Children, agreed. Guidelines are connected to outcomes by evidence and when that evidence isn’t applied, the results we’re aiming for won’t be realized.
As we move forward in implementing the new PNC guidelines, we must do so carefully, to both maintain fidelity but also ensure the care is meeting the needs of the women and children it is meant to serve. Certain aspects of the guidelines, like facility watch for 24 hours after birth, may inhibit facility delivery for women who, due to cultural or livelihood reasons, may not be able to stay that long. In addition, women and their families need supportive education as the world adopts new cord care standards that replace valued traditional practices.
Photo: ©2014 Katie Millar/MHTF