Post-partum mother and child care: a comparison of four African countries

Abstract

BackgroundRisk of morbidity and mortality during the post-partum period is high for mothers and children in sub-Saharan Africa. It is highest in the first 6 weeks after birth but stays high after 6 weeks because of issues such as untreated anaemia or repeat pregnancy. Improvement of delivery of post-partum care has been neglected as a strategy for improving maternal, infant, and child health. The Missed Opportunities for Maternal and Infant Health project aims to design, implement, and assess interventions for the first post-partum year in Burkina Faso, Kenya, Malawi, and Mozambique. We compared each site to understand how post-partum services could be more effectively organised. MethodsWe used a mixed methods approach to collect data about national post-partum policy, factors that affect health system change, and barriers to provision of, and demand for, post-partum care. We searched Google and Google Scholar, PubMed, and individual sites to identify major national and local documents, supplemented by advice from key local informants. In each setting, we consulted local implementers, managers, and policy makers. We did semi-structured interviews with between four and eight stakeholders at national, regional, and district levels, and two to three focus groups of ten to 15 participants at each site. Interviewees were selected on the basis that they would be able to provide the information that was needed. We collected data about current post-partum care processes and outcomes for each site. We critically analysed each setting and key similarities and contrasts between settings. FindingsIn all four study countries, maternal, infant, and child health is a national priority but specific policy for post-partum care, particularly for maternal health, is weak. All countries use a problem-driven approach to post-partum care; neither preventive care nor strategies that improve early identification of complications are prioritised. Emphasis on provision of evidence-based post-partum care varies between countries, with the most policy gaps in Burkina Faso. Dissemination of guidance at provincial to district levels is poor at all sites, which contributes to failure to implement, along with low staff capacity, poor quality of services, lack of knowledge in the community, and use of traditional practices that delay or inhibit care. 19% of women in Burkina Faso, 33% in Kenya, 41% in Malawi, and 40% in Mozambique received post-partum care in the first 7 days after delivery. For facility-based deliveries, immediate post-partum care was provided at almost all sites, usually by skilled health personnel, although women were often discharged early. Few health facilities provided subsequent post-partum care; 53 of 86 at 72 h and 28 of 86 at 7 days. The estimated proportion of deliveries that occur in the community ranged from 20% in Kaya, Burkina Faso to 60% in Kwale, Kenya, restricting skilled post-partum care. At least 70% of infants attended the health facility for BCG vaccine. InterpretationPost-partum care is poorly prioritised in maternal, infant, and child health national policy in all four study countries (although some variation exists), despite this period being high risk for both mother and child. This approach has led to implementation failures at district and service delivery levels. Increased knowledge and awareness among health providers of health-care needs in the first postnatal week, as part of general health systems strengthening, is needed to improve facility-based care. Service integration could be encouraged through international and national policy drives, and delivery of maternal and child health services could be more closely aligned—high rates of attendance at facilities for reasons related to child health, especially vaccination, provide an opportunity. Because delivery in the community is common, a well-developed strategy for raising awareness and provision of post-partum care in the community is needed to improve coverage and compensate for poor access to facility-based care. FundingEuropean Union.