Quality Of Postnatal Care Research Articles

Can reproductive health voucher programs improve quality of postnatal care? A quasi-experimental evaluation of Kenya's safe motherhood voucher scheme.

This study tests the group-level causal relationship between the expansion of Kenya’s Safe Motherhood voucher program and changes in quality of postnatal care (PNC) provided at voucher-contracted facilities. We compare facilities accredited since program inception in 2006 (phase I) and facilities accredited since 2010-2011 (phase II) relative to comparable non-voucher facilities. PNC quality is assessed using observed clinical content processes, as well as client-reported outcome measures. Two-tailed unpaired t-tests are used to identify differences in mean process quality scores and client-reported outcome measures, comparing changes between intervention and comparison groups at the 2010 and 2012 data collection periods. Difference-in-differences analysis is used to estimate the reproductive health (RH) voucher program’s causal effect on quality of care by exploiting group-level differences between voucher-accredited and non-accredited facilities in 2010 and 2012. Participation in the voucher scheme since 2006 significantly improves overall quality of postnatal care by 39% (p=0.02), where quality is defined as the observable processes or components of service provision that occur during a PNC consultation. Program participation since phase I is estimated to improve the quality of observed maternal postnatal care by 86% (p=0.02), with the largest quality improvements in counseling on family planning methods (IRR 5.0; p=0.01) and return to fertility (IRR 2.6; p=0.01). Despite improvements in maternal aspects of PNC, we find a high proportion of mothers who seek PNC are not being checked by any provider after delivery. Additional strategies will be necessary to standardize provision of packaged postnatal interventions to both mother and newborn. This study addresses an important gap in the existing RH literature by using a strong evaluation design to assess RH voucher program effectiveness on quality improvement.

Promoting healthy growth and nutrition in preterm infants: A challenge for clinicians and researchers

The ultimate goal of the quality post-natal care of premature infants is to provide an extra-uterine environment with high resemblance to intra-uterine life and primed for an undisrupted growth and development. Ideally, neonatal intensive care shall provide premature infants with equal chances in all aspects of development compared to as their counterparts in utero until they reach term age. However, in real life, preterm birth causes major deviations in various aspects of physiology:

Coverage, quality of and barriers to postnatal care in rural Hebei, China: a mixed method study

BackgroundPostnatal care is an important link in the continuum of care for maternal and child health. However, coverage and quality of postnatal care are poor in low- and middle-income countries. In 2009, the Chinese government set a policy providing free postnatal care services to all mothers and their newborns in China. Our study aimed at exploring coverage, quality of care, reasons for not receiving and barriers to providing postnatal care after introduction of this new policy.MethodsWe carried out a mixed method study in Zhao County, Hebei Province, China from July to August 2011. To quantify the coverage, quality of care and reasons for not using postnatal care, we conducted a household survey with 1601 caregivers of children younger than two years of age. We also conducted semi-structured interviews with 24 township maternal and child healthcare workers to evaluate their views on workload, in-service training and barriers to postnatal home visits.ResultsOf 1442 (90% of surveyed caregivers) women who completed the postnatal care survey module, 8% received a timely postnatal home visit (within one week after delivery) and 24% of women received postnatal care within 42 days after delivery. Among women who received postnatal care, 37% received counseling or guidance on infant feeding and 32% on cord care. 24% of women reported that the service provider checked jaundice of their newborns and 18% were consulted on danger signs and thermal care of their newborns. Of 991 mothers who did not seek postnatal care within 42 days after birth, 65% of them said that they did not knew about postnatal care and 24% of them thought it was unnecessary. Qualitative findings revealed that staff shortages and inconvenient transportation limited maternal and child healthcare workers in reaching out to women at home. In addition, maternal and child healthcare workers said that in-service training was inadequate and more training on postnatal care, hands-on practice, and supervision were needed.ConclusionsCoverage and quality of postnatal care were low in rural Hebei Province and far below the targets set by Chinese government. We identified barriers both from the supply and demand side.

Protocol for a systematic review on inequalities in postnatal care services utilization in low- and middle-income countries

BackgroundEach year, 287,000 women die from complications related to pregnancy or childbirth, and 3.8 million newborns die before reaching 28 days of life. The near totality (99%) of maternal and neonatal deaths occurs in low- and middle-income countries (LMICs). Utilization of essential obstetric care services including postnatal care (PNC) largely contributes to the reduction of maternal and neonatal mortality and morbidity. There is a strong need to evaluate the evidence on the unmet needs in utilization of PNC services to inform health policy planning. Our objective is to assess systematically the socioeconomic, geographic and demographic inequalities in the use of PNC interventions in low- and middle-income countries.Methods/DesignThe current protocol adopts a strategy informed by the guidelines of The Cochrane Handbook for Systematic Reviews. Our systematic review will identify studies in English, French, Spanish, Portuguese and Chinese – provided inclusion of an English abstract - from 1960 onwards, by searching MEDLINE (PubMed interface), EMBASE (OVID interface), Cochrane Central (OVID interface) and the gray literature. Study selection criteria include research setting, study design, reported outcomes and determinants of interest. Our primary outcome is the utilization of PNC services, and determinants of concern are: 1) socioeconomic status (for example, income, education); 2) geographic determinants (for example, distance to a health center, rural versus urban residence); and 3) demographic determinants (for example, ethnicity, immigration status). Screening, data abstraction, and scientific quality assessment will be conducted independently by two reviewers using standardized forms. Where feasible, study results will be combined through meta-analyses to obtain a pooled measure of association between utilization of PNC services and key determinants. Results will be stratified by countries’ income levels (World Bank classification).DiscussionOur review will inform policy-making with the aim of decreasing inequalities in utilization of PNC services. This research will provide evidence on unmet needs for PNC services in LMICs, knowledge gaps and recommendations to health policy planners. Our research will help promote universal coverage of quality PNC services as an integral part of the continuum of maternal and child health care. This protocol was registered with the Prospero database (registration number: CRD42013004661).

Care providers’ views and experiences of postnatal care in private hospitals in Victoria, Australia

Objectivein Australia, as in other developed countries, women have consistently reported lower levels of satisfaction with postnatal care compared with antenatal and intrapartum care. However, in Victoria Australia, women who receive private hospital postnatal care have rated their care more favourably than women who received public hospital care. This study aimed to gain a further understanding of this by exploring care providers’ views and experiences of postnatal care in private hospitals. Designqualitative design using semi-structured interviews and thematic analysis. Settingprivate maternity hospitals in Victoria, Australia. Participantseleven health-care providers from three metropolitan and one regional private hospital including eight midwives (two maternity unit managers and six clinical midwives) and three obstetricians. Findingstwo global themes were identified: ‘Constrained Care’ and ‘Consumer Care’. ‘Constrained care’ demonstrates the complexity of the provision of postnatal care and encompasses midwives’ feelings of frustration with the provision of postnatal care in a busy environment complicated by staffing difficulties, a lack of continuity and the impact of key players in postnatal care (including visitors, management and obstetricians). ‘Consumer care’ describes care providers’ views that women often approach private postnatal care as a consumer, which can impact on their expectations and satisfaction with postnatal care. Despite these challenges, care providers, particularly midwives, highly valued (and generally enjoyed working in) postnatal care. Key conclusionsthis study, along with other Australian and international studies, has identified that hospital postnatal care is complex and characterised by multiple barriers which impact on the provision of quality postnatal care. Further research is needed to evaluate routine postnatal practices and continuity of care within the postnatal period. In-depth qualitative studies investigating women's expectations and experiences of postnatal care in both the public and private sector are also needed.

Does delivery mode affect women’s postpartum quality of life in rural China?

To explore the impact of delivery mode on women's postpartum quality of life in rural China and probe factors influencing postnatal quality of life. Childbirth significantly affects puerpera's physical, psychological and social domains of quality of life. Under the circumstance of increasing high caesarean section rate in rural China, the impact of delivery mode on postnatal quality of life remains unclear. Cross-sectional study design. Women residing in rural areas and in their 0-12 months after childbirth from 30 rural townships participated in a household survey. A structured questionnaire was used to evaluate women's socio-demographic characteristics, previous pregnant experiences, foetal characteristics and use of maternal health services. The scale for rural postnatal quality of life was adopted to assess postnatal quality of life from six dimensions: physical complaints and pain, sleep and energy, sex satisfaction, interpersonal communication, self-evaluated living stress and perceived life satisfaction. The overall caeserean section rate was 70·0% (962/1375), and most of them (59·7%) were selected by maternal request. None of six dimensions and total score of quality of life displayed significant difference between women with normal delivery and cesaerean section. It was found that postnatal home visit related to good postnatal quality of life and lower husband education level, male gender of infant were associated with poor quality of life. Delivery mode did not affect postpartum quality of life in rural China. Socio-cultural determinants may contribute more in influencing postnatal quality of life. Null findings in impact of delivery mode on postpartum quality of life may cause more difficulties in maternal decision-making for vaginal delivery in rural China. The importance of postnatal home visit could justify available and quality postnatal care in improving postpartum quality of life. Further research needs to explore the effective prevention programmes, especially attention for parenting boys.

Low postnatal care rates in two rural counties in Anhui Province, China: Perceptions of key stakeholders

Objective to explore the perceptions of stakeholders on postnatal care and to describe the rate of postnatal home visits in two rural counties in Anhui Province, China. Design this was a mixed methods study which uses mainly qualitative methods including focus group discussions, in- depth interviews and key informant interviews. A household survey of postpartum women was used to calculate the rates of postnatal home visits. Setting two rural counties in Anhui Province, China. Participants qualitative study participants: officials responsible for maternal health care at county level, health providers at township and village level and maternal health-care users. Household survey participants: 2326 women who gave birth in the two counties from January 2005 to December 2006. Findings the survey of postpartum women revealed that only 4.2% and 4.5% of women received one or more postnatal visits at home in County A and County B. Qualitative interviews revealed a range of perceived reasons for this low rate of provision and utilisation of postnatal care, including: inadequate funding for maternal health care; limited human resources; lack of transport in township hospitals; and limited value placed on postnatal care by women and providers. In addition, where services were provided, a number of factors were likely to restrict health providers from delivering high-quality postnatal health service, such as: weak skills and knowledge of staff; inadequate in-service training; lack of equipment in township hospitals; and poor supervision and monitoring. Key conclusions the rate of postnatal visits was extremely low in two counties in rural China. Understaffing and inadequate funding are the main factors that affect provision of postnatal health care. Implications for practice more emphasis should be attached to political support and funding for postnatal care. Research into feasible ways to provide quality postnatal care needs to be conducted.

Integrating quality postnatal care into PMTCT in Swaziland

Swaziland's prevention of mother-to-child transmission (PMTCT) programme is linked to maternal and newborn health (MNH) services, but is mainly focussed on HIV/AIDS. Existing MNH services are inadequate, especially postnatal care (PNC) of mothers and babies, with delayed postnatal visits occurring at 4–6 weeks after delivery. Fifty-seven percent of staff in seven Swazi health facilities were trained in promoting and providing early PNC. A final evaluation showed a 20-fold increase in the number of visits coming for an early postnatal visit (within the first three days after birth). A direct observation of the client–provider interaction showed a significant increase in the competence of the health workers related to postnatal examinations, and care of mothers and babies (p<0.05– < 0.01). The percentage of women breastfeeding within one hour of delivery increased by 41% in HIV-positive mothers and 52% in HIV-negative mothers. Cotrimoxazole prophylaxis for HIV-exposed infants increased by 24%. Although, health workers were observed providing counselling, maternal recall of messages was deficient, suggesting the need for additional strategies for promoting healthy behaviours. High-quality integrated PMTCT programmes and MNH postnatal services are feasible and acceptable, and can result in promoting early postnatal visits and improved care of both HIV-positive and HIV-negative mothers and their babies.

Staffing in postnatal units: is it adequate for the provision of quality care? Staff perspectives from a state-wide review of postnatal care in Victoria, Australia

BackgroundState-wide surveys of recent mothers conducted over the past decade in Victoria, one state of Australia, have identified that women are consistently less satisfied with the care they received in hospital following birth compared with other aspects of maternity care. Little is known of caregivers' perspectives on the provision ofhospital postnatal care: how care is organised and provided in different hospitals; what constrains the provision of postnatal care (apart from funding) and what initiatives are being undertaken to improve service delivery. A state-widereview of organisational structures and processes in relation to the provision of hospital postnatal care in Victoria was undertaken. This paper focuses on the impact of staffing issues on the provision of quality postnatal care from the perspective of care providers.MethodsA study of care providers from Victorian public hospitals that provide maternity services was undertaken. Datawere collected in two stages. Stage one: a structured questionnaire was sent to all public hospitals in Victoria that provided postnatal care (n = 73), exploring the structure and organisation of care (e.g. staffing, routine observations, policy framework and discharge planning). Stage two: 14 maternity units were selected and invited to participate in a more in-depth exploration of postnatal care. Thirty-eight key informant interviews were undertaken with midwives (including unit managers, associate unit managers and clinical midwives) and a medical practitioner from eachselected hospital.ResultsStaffing was highlighted as a major factor impacting on the provision of quality postnatal care. There were significant issues associated with inadequate staff/patient ratios; staffing mix; patient mix; prioritisation of birth suites over postnatal units; and the use of non-permanent staff. Forty-three percent of hospitals reported having only midwives (i.e. no non-midwives) providing postnatal care. Staffing issues impact on hospitals' ability to provide continuity of care. Recruitment and retention of midwives are significant issues, particularly in rural areas.ConclusionStaffing in postnatal wards is a challenging issue, and varies with hospital locality and model of care. Staff/patient ratios and recruitment of midwives in rural areas are the two areas that appear to have the greatest negative impact on staffing adequacy and provision of quality care. Future research on postnatal care provision should include consideration of any impact on staff and staffing.

Modeling human mortality using mixtures of bathtub shaped failure distributions

Aging and mortality is usually modeled by the Gompertz–Makeham distribution, where the mortality rate accelerates with age in adult humans. The resulting parameters are interpreted as the frailty and decrease in vitality with age. This fits well to life data from ‘westernized’ societies, where the data are accurate, of high resolution, and show the effects of high quality post-natal care. We show, however, that when the data are of lower resolution, and contain considerable structure in the infant mortality, the fit can be poor. Moreover, the Gompertz–Makeham distribution is consistent with neither the force of natural selection, nor the recently identified ‘late life mortality deceleration’. Although actuarial models such as the Heligman–Pollard distribution can, in theory, achieve an improved fit, the lack of a closed form for the survival function makes fitting extremely arduous, and the biological interpretation can be lacking. We show, that a mixture, assigning mortality to exogenous or endogenous causes, using the reduced additive and flexible Weibull distributions, models well human mortality over the entire life span. The components of the mixture are asymptotically consistent with the reliability and biological theories of aging. The relative simplicity of the mixture distribution makes feasible a technique where the curvature functions of the corresponding survival and hazard rate functions are used to identify the beginning and the end of various life phases, such as infant mortality, the end of the force of natural selection, and late life mortality deceleration. We illustrate our results with a comparative analysis of Canadian and Indonesian mortality data.

Evaluating a new course in postnatal care

An innovative course has been developed and implemented to enable midwives to extend their role in the postnatal period. This is in response to the challenge for midwives to enhance their public health role. On completion of the course participants felt that they had developed practical strategies about where and how to improve the quality of postnatal care, up to and including the 6–week postnatal examination. This article reviews and evaluates this course and makes some suggestions for future developments for both education and practice.

Debriefing after childbirth: a tool for effective risk management

The caring function of the traditional extended family is increasingly being passed on to the maternity services. The midwife needs to re-examine the provision and nature of the care she/he delivers. The experience of the Oxford group in extending the parameters of postnatal care has shown that debriefing after childbirth not only enhances the quality of postnatal care to women and their families, but provides an avenue for effective risk management.

The phenomenon of caring by the midwife.

The child-bearing events are normal physiological processes in the body of the woman and embryo-foetus/baby. Many changes in the internal and external environments of the family take place, simultaneously with these normal processes. These changes lead to the development of certain tasks and responsibilities that must be successfully accomplished by the family during the child-bearing events. Many changes have also taken place in midwifery during the last half of this century. These changes in midwifery practice, together with the changes that take place during child-bearing events, may cause the new family to feel insecure during this stage of their lives. Very often when the family comes into contact with the midwife the factors contributing to feelings of insecurity are present already or soon become present. Their insecurity causes the family to look to the midwife for help and support. The questions that arise are: What are the caring activities which the midwife should carry out to assist and facilitate the new family to grow on the health continuum during the postnatal period? How can the humanistic values of caring be combined with the scientific knowledge base that guides the midwife's actions to form the science of caring? A description of the midwife's caring functions during the post-natal period, in the hospital as well as in the community, is therefore essential. Thereafter, formulation of valid standards for postnatal care by the midwife can contribute to quality post-natal care in South Africa.

The standards for postnatal care by the midwife in the hospital and the community.

The child-bearing events are normal physiological processes in the body of the woman and embryo/foetus/baby. Many changes in the internal and external environments of the family take place, simultaneously with these normal processes. These changes lead to the development of certain tasks and responsibilities that must be successfully accomplished during the postnatal period. A description of the midwife's caring functions during the post-natal period, in the hospital as well as in the community, is therefore essential. This description forms the part of an article that was published in the previous issue of Curationis. Thereafter the formulation of valid standards for postnatal care by the midwife can contribute to quality post-natal care in South Africa. The aim of this second part of the study was to formulate valid general standards for postnatal care by the midwife; Concept standards were formulated with the model of postnatal care and the stated prerequisites of caring as conceptual framework. The statistical validity of all the standards were determined by midwifery experts.