Status of Community Based Postpartum Care Services: Analysis of Survey Findings May Post, MD, MBBS, DP&TM
Senior RH Advisor, CATALYST March 2005
I. About the Survey
Survey Objective: To find out the current status of delivery of community-based postpartum care (CBPPC) services and identify commonalities and differences across country projects. Methodology: For the survey, questionnaires were sent out to participants from 13 bilateral projects who had been invited to the Network meeting. 12 projects responded (10 ongoing and 2 new) representing 8 countries.
Afghanistan Rural Expansion of Afghanistan’s Community-based Health Care (REACH)
Bangladesh USAID-Municipality-Concern Child Survival Project (CSP) NGO Service Delivery Program (NSDP)
Saving Newborn Lives (SNL/B)
Cambodia Reproductive and Child Health Alliance (RACHA) CARE Health Sector Program (HSP)
E. Timor Strengthening Maternal and Newborn Care (New)
India Reproductive & Child Health, Nutrition and HIV/AIDS (RACHNA)
Nepal SNL/N
Nepal Family Health Project (NFHP)
Pakistan Pakistan Initiative for Mothers and Newborns (PAIMAN) (New)
Yemen CATALYST
II. About the Projects Commonalities
All projects have an overall focus on maternal and child health. Differences
When asked about project focus areas, some projects cited training, some responded service delivery and some identified community mobilization. There were also differences in target
populations covered, private sector involvement, and ongoing partner involvement. Three projects covered urban populations, compared to the majority targeting rural populations; four projects specified private sector involvement; and three projects (two in Cambodia and one in India) identified specific nonhealth partner organizations. Only one project in Cambodia specifically mentioned involvement of “other” community members (other than CHWs [community health workers and TBAs [trained birth attendants]) in CBPPC.
Training
• Establishing community MW schools; midwifery education revision and improving facility-based EOC. (REACH/Afghan)
• Training government Midwives (MWs) in Life Saving Skills (LSS) (RACHA) Service delivery
• Urban maternal and child health and IMCI (Integrated management of childhood illnesses) focusing on ARIs, (acute respiratory infections) diarrhea and malnutrition (Concern CSP-Bangladesh)
• Postpartum and neonatal care; Community-based health promotion (E. Timor)
• CS, FP, RTI/STI (reproductive tract infection/sexually transmitted infection) prevention and management (RACHNA /India)
• Home-based safe delivery (NSDP/Bangladesh) Community mobilization
• TBA-Midwife Alliance provide incentives to TBAs to refer expecting mothers to midwives (CARE HSP/Cambodia)
• Poverty screening and subsidizing women with equity funds to access emergency care and other basic services (CARE HSP/Cambodia)
• Community transportation system for referrals (RACHA/Cambodia) Policy
• Policy support (E. Timor) Target populations:
Three projects covered urban populations. One focused exclusively on urban health (Concern CSP/Bangladesh).
Private Sector involvement
Four projects (PAIMAN/Pakistan; NFHP/Nepal; CARE HSP/Cambodia, RACHNA/India) indicated private sector involvement.
Nonhealth partner involvement
Three projects (two in Cambodia and one in India) specified involvement of nonhealth partners as follows:
Cambodia
Ministry of Education
Ministry of Provincial Rural Development Ministry of Women’s Affairs
India
Women and Child Development Department, GOI (Government of India) Health and Family Welfare Department, GOI
Local governance institutes and bodies Community-based organizations
Community Involvement (other than CHWS and TBAs)
• One project (in Cambodia) specifically mentioned involvement of other community members other than CHWs and TBAs. Community members specified include: Village chief
Commune chief Religious leaders Village shopkeepers
Village health support groups III. Policies
Policies that Promote Some examples follow: Afghanistan
• National strategy for reduction of mortality and morbidity from PPH • National Clinical Standards for PPC
• National Clinical Standards for Newborn Care Bangladesh
• Maternal Health Strategy
• HNP Sectoral Plan (includes clarification of technical standards, Quality of Care and monitoring checklist, interaction with women and their families to ensure PPC visits) Cambodia
• National policy for safe motherhood (emphasizing postnatal home visit; postpartum birth spacing and birth spacing for postabortion care.)
• SM protocol (maternal and newborn care and management of selected PP problem) Pakistan
• National program for FP and PHC (Lady Health Workers providing PPC in the rural communities)
E. Timor
• National PPC policy being developed India
• National Population Policy
• National Nutrition Policy and Plan of Action Nepal
• National SM Plan
• National Neonatal Health Strategy Policies that Hinder
The following were mentioned by respondents:
• Paramedics not allowed to use oxytocin • No emphasis on PP FP
• Lack of guidelines for PPC (in comparison antenatal care [ANC] guidelines exist) • Definition of PP visit as any visit within 42 days of delivery
• TBAs/community volunteers not allowed to distribute vitamin A to PP women IV. Provision of PPC
4.1 Projects providing PPC at the facility and community levels (CARE HSP/Cambodia, RACHA/Cambodia, REACH/Afghanistan, NFHP/Nepal)
Commonalities and Differences8
Frequency and Timing of PPC Provision (varies across the 4 projects)
Projects Immediate PP 1st week PP 6 weeks PP
RACHA/C (3) x x x CARE HSP/C (2) x x REACH/A (2) x x NFHP/N (once) x Providers Facility level
• Mostly Nurses and Midwives (with doctors in some settings) Community level
• CHWs, Auxiliaries, trained TBAs
• Midwives (HSP and RACHA in Cambodia); community midwives (REACH in Afghanistan)
• NGO workers, paramedics Location of Service Delivery Facility level
• Health center Community level
• Home
• Community health clinic in some settings (REACH, NFHP) Skills and Services
HC level
• General PP assessment of the mother (anemia, uterus, lochia/bleeding, breast, perineal infection); general newborn care (breathing, warmth, weight, cord, eyes, feeding) • Maternal complications: PPH , puerperal sepsis, managed in some (but not all) settings
8
• Newborn complications commonly managed: perform resuscitation for asphyxia, manage convulsions, treat infections
Community level
• Community MWs and trained TBAs do general exams and counseling, but have limited ability to manage complications, which are referred.
• Other community-level workers (e.g., CHWs)—register and report deliveries, and recognize and refer danger signs.
• In one project, MWs are trained in LSS and can give oxytocin, parenteral antibiotics at the community level (RACHA/C
• In another CHWs and village health support groups (VHSGs) provide Vitamin A and Fe (HSP/C).
• Project-sponsored community transportation system set up for referrals was reported by one project (RACHA/C).
• Poverty screening and subsidizing poor women through equity funds to access care was cited by another (CARE HSP/Cambodia).
4.2 Projects providing PPC at the facility level only (NSDP/Bangladesh, CATALYST/Yemen))
Frequency and Timing of PPC
• Once: 6 weeks postpartum when mothers come to have their babies immunized (NSDP/B) • PPC provided during scheduled visits to health centers by CATALYST mobile teams
(CATALYST/Yemen) Location of Service Delivery
• NGO clinics (NSDP/B)
• Mobile teams (visiting health facilities) (CATALYST/Yemen) Providers
• Nurses and midwives (doctors in some settings) • NGO workers
Services provided
• Only specific PPC activities are provided e.g., check episiotomy; treat or refer complications (NSDP/B)
• Mobile teams train HC staff in FP(Family Planning) counseling; and provide Family Planning/Birth Spacing counseling and provision of PP FP, i.e., IUDs for women 4-6 weeks PP (CATALYST/Yemen)
Reasons for nonprovision at the community level (NSDP/B) • Not considered a priority by the government
• Health care workers too busy to do outreach/home visits
4.3 Projects providing PPC at the community level only (Concern CSP/Bangladesh; SNL/Bangladesh; SNL/Nepal; RACHNA/India)
Frequency and Timing of PPC (varies across projects)
Projects Immediate PP 1st week PP 6 week PP Other
Concern CSP/B x x x RACHNA/I x x x SNL/N w/in 72 hours & 4-6 days 6-28 days
SNL/B Birth-6 hours 6-28 days
Location of Service Delivery • Commonly home
• Community health clinic in some settings Providers
• CHWs, trained TBAs, private practitioners • NGO workers in some settings
Services Provided
• Routine PP monitoring of mother; routine newborn care; counseling on maternal and newborn care
• Complications referred to next level
• Immediate newborn care; common newborn problems such as LBW (SNL/Bangladesh) • Extra care for LBWs; newborn infection prevention (SNL/Nepal)
4.4 New projects
• PPC services planned (Pakistan, E. Timor)
• The priority focus of the E. Timor program is on developing policy and strategy for PPC including CBPPC
4.5 Frequency and Timing of PPC among the 10 ongoing projects that responded Frequency and timing of PPC provision varied widely across the projects
Among the 10 ongoing projects which responded:
• Four projects (CSP/Bangladesh, RACHA/Cambodia, RACHNA/India, SNL/Nepal) provided PPC three times
• Another four (REACH/Afghanistan; CATALYST/Yemen; CARE HSP/Cambodia; SNL/Bangladesh) provided PPC two times
• Two projects (NFHP/Nepal, NSDP/Bangladesh) provided PPC services once at six weeks postpartum
Among the four projects providing PPC three times, three provided PPC immediate PP (1st 24 hours); 1st week PP (2-7 days) and 6 weeks PP (8-42 days); and one project (SNL/Nepal) provided PPC, within 72 hours; 4-6 days; and 6-28 days (see table below).
Projects Immediate PP 1st week PP 6 weeks PP Concern CSP/B x x x RACHA/C x x x RACHNA/I x x x SNL/N w/in 72 hours & 4-6 days 6-28 days
Among the four projects providing PPC two times, two provided PPC 1st week PP (2-7 days) and 6 weeks PP (8-42 days); one (CARE HSP/Cambodia) provided PPC immediate PP and 6 weeks PP; and another (SNL/B) provided PPC birth to 6 hours, and 6 days to 28 days (see table below). PPC 2 times
Projects Immediate PP 1st week PP 6 weeks PP
REACH/A x x
CATALYST/Y x x
CARE HSP/C x x
SNL/B Birth-6 hours 6 -28 days
V. Postpartum Counseling Commonalities
• Counseling was provided by all the projects
• Common topics were: BF, nutrition, newborn care and immunization and danger signs Differences
• Some (NOT ALL) projects included the following in their PP counseling: hygiene; birth spacing and family planning; and harmful practices.
• One project provided counseling on breastfeeding, danger signs, birth spacing and nutrition ONLY during antenatal care. (NSDP)
VI. Identification of Postpartum Women for PPC Services Commonalities and Differences
Women delivered by MWs (CMWs (community midwives), private MWs) receive PPC services from the midwives who attended their deliveries.
Differences are seen in deliveries NOT attended by midwives. The common feature/commonality is the use of community-based workers, but the approaches are different.
• CHVs (unpaid volunteers) are assigned to a certain number of households. When a delivery occurs in a household they are assigned to, they provide information to health workers. (Concern CSP/Bangladesh)
• TBAs and Village Health Groups report on a monthly basis to the HC on deliveries attended by TBAs. (Cambodia)
• LHWs who are responsible for a certain no. of households have records of pregnant women and know when the delivery takes place in their catchment area. (Pakistan) • Through a pregnancy register maintained by the project ANM with support from local
TBAs and community volunteers. (Nepal)
• A community-based worker (Anganwadi) registers pregnancies occurring in the area she covers and ensures that mothers receive care by the ANMWs. Each Anganwadi covers approximately 1,000 people. (India)
• A community mapping tool is used by CHWs to track postpartum women and refer them to a health facility. (Afghanistan)
VII. Training of community level providers Commonalities and Differences
Trainers
• The community-level providers are commonly trained by the government and the project.
• In a few projects, community level providers are trained by partner NGOs as well. Skills
Maternal Care
• In general, community MWs and TBAs are trained to perform general exams and counseling, but have limited ability to manage complications which are referred.
• In a few, MWs providing care at the community level are trained in Life Saving Skill and can give oxytocin and parenteral antibiotics at the community level (e.g.,
RACHA/Cambodia).
• In another, community midwives are trained in postpartum physical examination, counseling and targeted service provision (REACH).
• Related to other categories of community level workers, their skills are, in general, to recognize and refer danger signs, and to report deliveries.
• In some settings, CHWs can give Vitamin A and Fe. (Cambodia) Newborn Care
• In a few projects, CHWs are trained in newborn resuscitation and care of low birth weights (LBWs). (Bangladesh, Nepal)
Duration of training
PPC training is usually integrated with other components in the training package. Except for TBAs, the duration of training of other categories of community-level providers varied across projects.
• TBAs: 5-7 days
• CHWs: duration ranged from 5 days (India, SNL/B) in some projects to 21 days in one project (Concern CSP/Bangladesh) and 9 weeks in another (REACH/Afghanistan) • CMWs: duration ranged from 2-3 weeks in one project (life saving skills LSS training,
Duration of Training of Community Level Providers
TBA CHW MCHW CMW
5-7 days 5 days – 9 weeks 90 days 2 weeks – 18
months
VIII. Challenges and Barriers (Responses by all 12 projects, ongoing plus new) Responses at each level are listed in order of frequency.
Policy Level
• Lack of funds/resource allocation (5/12)
• Not considered a priority at the policy level (3/12) Service delivery level
• Health center considered too far to come for postpartum care checkups (9/12) • Health care providers not adequately trained in PPC (8/12)
• No funds/resources for outreach visits or supervisory visits (6/12) Community level
• Not considered a priority by family members (9/12) • Community-level providers not adequately trained (8/12) • PPC provided at home by family member (8/12)
• Most women deliver at home. Difficulty in finding just-delivered/postpartum women who delivered at home
Others
Other challenges and barriers are also reported. Policy Level
• Policy focus in PPC only on vitamin A, Fe/folic provision (rather than a range of maternal care) and newborn immunization (rather than a range of newborn care) (Cambodia)
• Lack of effective system to implement PPC policy • Limited advocacy for PPC
Service delivery level
• Geographical and logistical challenges (E Timor) • Lack of provider motivation due to lack of supervision • Unfilled government provider positions (India)
Community level • Inadequate BCC
• Lack of health care providers’ community mobilization skills to support community- based PPC activities
• CHWs do not see PPC provision as part of their work
• Traditional practices (e.g., postpartum seclusion which discourages women from leaving home for first 2-3 months; dietary restrictions; belief that new mothers and babies are considered “polluted.”)
IX. Monitoring and Evaluation of PPC Services Commonalities
Indicators related to (1) postpartum checkups, (2) breastfeeding and (3) vitamin A supplementation and (4) counseling are common.
Differences
Differences are seen in indicator definitions by various projects. See examples below. Postpartum Check-Ups
• % of women who had postpartum checkup within 48 hours postdelivery (Concern CSP/Bangladesh, CARE HSP/Cambodia)
• % of mothers who received PPC within 3 days of delivery (SNL/Bangladesh) • % of mothers who received PPC within 1 week of delivery (SNL/Bangladesh)
• % of women who had postpartum checkup by MWs trained in LSS (RACHA/Cambodia) • Proportion of mothers and newborns contacted on 1st day and 1st week (for PPC) by
health center worker (RACHNA/India) Breastfeeding
• % of mothers who breastfed their infant within one hour of birth (SNL/B) • % of women breastfeeding baby within 24 hours after birth (HSP/Cambodia) • % of mothers who breastfed their infants exclusively at 1 month (SNL/B)
• % of children born in the last 12 months who were breastfed within 1 hour after birth (RACHA/Cambodia)
• % of children under 6 months exclusively breastfed (RACHA/Cambodia) Vitamin A supplementation
• % of postpartum women who received Vitamin A supplementation within 8 weeks after delivery (RACHA/Cambodia, E. Timor)
• % of postpartum mothers and newborns receiving Vitamin A supplementation (Concern CSP/Bangladesh)
• % and no. of postpartum women who received Vitamin A within 8 weeks after delivery (HSP/Cambodia)
Counseling
• Proportion of mothers advised on newborn care by HCW (India)
• % of mothers receiving PPC who were counseled in at least 2 danger signs (SNL/B) • % of women with infants < 1 year of age who know at least 3 danger signs of newborn
• % of WRA who know where to go for complications during childbirth (PAIMAN/Pakistan)
• % of husbands who know where to go for complications during childbirth (PAIMAN/Pakistan)
Newborn care specific
• Proportion of newborns dried and wrapped immediately after birth. (RACHNA/India) • Proportion of newborns for whom nothing was applied to the cord at birth till cord falls
off (RACHNA/India) Other Indicators
• % of postpartum women who consumed Fe for 42 days (CARE HSP/Cambodia)
• % of postpartum women who adopted a family planning method (CARE HSP/Cambodia) • % of MNC supervision visits achieve score of 75% or higher
Note on Indicators: Only one project (CARE HSP/Cambodia) included an indicator on PP /FP.
X. Improving PPC (responses by all 12 projects)
The question was: “What is needed to promote/ improve community-based PPC?” The responses are:
Advocacy (12/12)
Operations Research (OR) (12/12) Areas for OR suggested are as follows:
• different methods of delivering PPC (E Timor) • looking at PP health seeking behavior (NSDP/B)
• how to get health workers to the home soon after birth (REACH/A)
• minimum standards of PPC that can be provided in outreach services (Concern CSP/B) • how to best to utilize existing community-based providers for PPC delivery (Concern
CSP/B)
• feasibility and impact of implementing a basic newborn care package in resource poor settings, at scale (RACHNA/India)
• operationalization of first referral unit to provide comprehensive obstetric care (RACHNA/India)
Behavior Change Communication (BCC) (10/12) • health care seeking behavior
• improved home care behavior (HSP/C) Training (10/12)
Suggested topics include:
• counseling on all manners of postpartum health (REACH)
• training community in communication skills(RACHA/Cambodia) • training families on birth preparedness (HSP/Cambodia)
• training community on community mobilization (SNL/B) Other (suggestions to improve PPC)
• promote and support home visits to identify mothers and newborns within 72 hours • pregnancy registration and follow-up
• mapping of CHWs that can be trained to PPC • increased resources for supervision and monitoring
Note on Improving PPC: None of the respondents mentioned/suggested role/involvement of “other” community members, nonhealth partners and private sector partners in improving PPC.
XI. Best Window of Opportunity to promote PPC
• “Before delivery” was the more frequent response compared to “after delivery.” Before delivery
• Antenatal Clinic (12/12)
• Home (11/12) (except NSDP/B)
• FP Clinic (3/12) (Yemen, Concern/B, NFHP/N) • Other:
Community mobilization and support groups
• facilitated discussions with the women and the families in the community (REACH)
• mass community mobilization involving all stakeholders (Concern CSP/B) • women’s groups
• group meetings After delivery
• Home (12/12)
• FP Clinic (5/12) (Yemen, CONCERN/B, PAIMAN, NFHP, SNL/B) • Other:
o Outreach services (RACHA/Cambodia)
• Community through support groups (HSP/Cambodia) • Vaccination and childcare services
• Traditional cultural practices (CATALYST/Yemen)
Note on Window of Opportunity: Similar to “improving CBPPC,” no respondent mentioned utilizing/involving “other” community members, nonhealth organizations/partners and private sector partners in PPC promotion. Are these missed opportunities?
XII. Lessons Learned from Project Experiences
Based on the responses received, the lessons learned have been organized into the following: identification of PP women; timing of PPC; providers; training; BCC and others.
Identification of postpartum women
• Mobilization of female community health workers (FCHWs) to identify newly delivered mothers and babies is a successful approach. (NFHP)
• Door to door visits by CHWs using community registers is effective. (SNL/Bangladesh) Timing of PPC
• Immediate PPC within 24 hours needs resources and motivation. (SNL/Bangladesh) • Reaching new mothers within 3 days is more feasible than immediate PPC.
(SNL/Bangladesh) Providers
• Engagement of government systems and advocacy at different service delivery levels ensured increased commitment by service providers. (India)
• Trained TBAs are key community resources for delivery care and PPC. (SNL/Bangladesh, RACHA/Cambodia)
• TBAs are well accepted by families for PPC. (SNL/Nepal)
• TBAs are able to perform general examinations and counseling to a reasonable standard with supervision. (SNL/Nepal)
• Provision of Vitamin A and Fe by TBAs led to increased coverage of target populations. (CARE HSP/Cambodia)
• Skills building of service providers in solving problems for behavior change form an important part of the program. (RACHNA/India)
Training
• Simply training midwives does not increase coverage of women delivering and receiving PPC from trained providers. Demand creation as well as practical solutions to
transportation, financial barriers are equally essential. (CARE HSP/Cambodia; Concern CSP/Bangladesh)
BCC
• When designing a BCC strategy, household-level barriers preventing adoption of new behaviors must be taken into consideration. (Concern CSP/Bangladesh)
• Mechanisms to address equity issues, especially gender dimensions that hinder adoption of behavior change by women, are important. (RACHNA/India)
Others
• Establishing TBA-Midwife alliances increase referral and PPC provision. (CARE HSP/Cambodia)
• Poverty screening and subsidizing poorer women by equity funds gives poorer women a chance to receive care from trained providers. (CARE HSP/Cambodia)
• Integration of EPI (Expanded Program on Immunization) with 6 weeks postpartum visits provide an opportunity for counseling and needed interventions. (NFHP/Nepal)
• In programs with no emphasis on impact, a program can become a set of predefined activities with no focus on outcomes and impact. (RACHNA/India)
• Lack of coordination between capacity building, BCC process and monitoring can derail the effectiveness of interventions. (RACHNA/India)
• Community-based PPC works when there is:
• Training/refresher training of community-based providers by facility-based providers • A formal referral linkage between community-based providers and the facilities • A mechanism is in place to establish accountability of community-based providers to
the community (community committees and structures) and health facility personnel. (USAID-Municipality-Concern Partnership CSP/B)
XIII. Conclusions Based on Survey Findings
• Unlike ANC, PPC is not considered a priority at the policy level or by the family. • There is much variation in the frequency and timing of PPC provision across projects. • Similarly, content and duration of training of community-level workers varies.
• If reaching mothers within the 1st 24 hours is not feasible, the earliest contact, at least once at day three, should be advocated.
• Facility-based routine PPC (except at 6 weeks PP) is not common.
• Facility-based routine newborn care (except immunization) is not generally practiced. • Maternal and newborn emergencies are usually not managed at the community level. In
general, complications are referred to the next level.