Abstract
ObjectiveTo assess the socioeconomic, geographical and demographic inequities in the use of postnatal health-care services in low- and middle-income countries.MethodsWe searched Medline, Embase and Cochrane Central databases and grey literature for experimental, quasi-experimental and observational studies that had been conducted in low- and middle-income countries. We summarized the relevant studies qualitatively and performed meta-analyses of the use of postnatal care services according to selected indicators of socioeconomic status and residence in an urban or rural setting.FindingsA total of 36 studies were included in the narrative synthesis and 10 of them were used for the meta-analyses. Compared with women in the lowest quintile of socioeconomic status, the pooled odds ratios for use of postnatal care by women in the second, third, fourth and fifth quintiles were: 1.14 (95% confidence interval, CI : 0.96–1.34), 1.32 (95% CI: 1.12–1.55), 1.60 (95% CI: 1.30–1.98) and 2.27 (95% CI: 1.75–2.93) respectively. Compared to women living in rural settings, the pooled odds ratio for the use of postnatal care by women living in urban settings was 1.36 (95% CI: 1.01–1.81). A qualitative assessment of the relevant published data also indicated that use of postnatal care services increased with increasing level of education.ConclusionIn low- and middle-income countries, use of postnatal care services remains highly inequitable and varies markedly with socioeconomic status and between urban and rural residents.
Highlights
Each year an estimated 289 000 women die worldwide from complications related to pregnancy, childbirth or the postnatal period[1] and up to two thirds of such maternal deaths occur after delivery.[2,3] Poor outcomes of maternal and neonatal care include 2.9 million neonatal deaths per year.[4]
The 36 studies included in our qualitative synthesis of evidence comprised two randomized controlled trials, three quasiexperimental studies, two cohort and 28 cross-sectional studies, and one investigation of 31 demographic and health surveys
A lack of information on methodology prevented the assessment of the scientific quality of one study included in the qualitative synthesis (Table 1, available at: http://www.who.int/bulletin/vol umes/93/4/14-140996)
Summary
Each year an estimated 289 000 women die worldwide from complications related to pregnancy, childbirth or the postnatal period[1] and up to two thirds of such maternal deaths occur after delivery.[2,3] Poor outcomes of maternal and neonatal care include 2.9 million neonatal deaths per year.[4]. According to the World Health Organization (WHO), the postnatal period begins immediately after childbirth and lasts six weeks.[6] In low-income countries, almost 40% of women experience complications after delivery and an estimated 15% develop potentially life-threatening problems.[7] Postnatal care services are a fundamental element of the continuum of essential obstetric care – which includes antenatal care and skilled birth attendance – that decreases maternal and neonatal morbidity and mortality in low- and middle-income countries.[8,9] Compared with other maternal and infant health services,[10] coverage for postnatal care tends to be relatively poor. Possible postnatal interventions for the mother include: (i) iron and folic acid supplementation for at least three months; (ii) screening for – and treatment of – infection, haemorrhage, thromboembolism, postnatal depression and other conditions; (iii) prophylactic antibiotics given to women who have a third- or fourth-degree perineal tear; and (iv) counselling on early and exclusive breastfeeding, nutrition, birth spacing and family planning options – including any available contraception.[14,16,17] Possible interventions for the neonate include: (i) care of the umbilical cord (ii) special care for preterm, low-birth-weight and HIV-infected neonates;[14,15,18] (iii) screening and treatment of infections and postnatal growth restriction; (iv) assessment of factors predisposing to infant anaemia;[19] and (v) teaching the mother to seek additional care for her neonate if she notices danger signs such as convulsions or problems with feeding.[14]
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