Horizons Report | June 2007 | Repositioning Postnatal Care

horizons_report.gif (8665 bytes)

June 2007

Repositioning Postnatal Care
Baseline results from Swaziland, a high HIV prevalence environment

A female counselor and a mother with an infant sit down for a counseling session.

New guidelines for postnatal care in Swaziland will encourage earlier and more frequent examinations of mother and baby.

Photo credit: Melissa May/©Population Council

The postnatal period can be a time of tragedy, as over 60 percent of maternal deaths occur in the first 48 hours after childbirth and two-thirds of neonatal deaths in the first 24 hours. Postnatal care, including early detection and management of complications, is critical for all mothers and newborns. For mothers living with HIV, the postnatal period is particularly crucial for receiving HIV-related services.

An estimated 39 percent of pregnant women are HIV-positive in Swaziland, which has one of the highest rates of HIV infection in the world. Approximately 17,000 HIV-exposed infants are delivered to mothers in Swaziland every year. While the use of antenatal care (ANC) services and prevention of mother-to-child transmission (PMTCT) programs is high, a major weakness is the follow-up of HIV-positive mothers and their babies after delivery.

National guidelines for postnatal care encourage all mothers to return to the maternal and child health (MCH) clinic six weeks after delivery. Horizons, in collaboration with the Swaziland Central Statistics Office and Ministry of Health and Social Welfare, is conducting research on changes to the guidelines to include earlier and more frequent examination of mother and baby. The new guidelines would recommend their examination before leaving the hospital, and again after one week and after six weeks. Through pre- and post-assessment, the research team is evaluating the impact of the revised service guidelines to see if they: 1) encourage an increase in the provision of the key components of essential care by health providers in the postnatal period, 2) increase utilization of postnatal care services among all women, and 3) improve the care and follow-up of HIV-positive women and their infants.

In 2006, researchers conducted a baseline study in three maternity units and four MCH or public health units. Data were gathered through facility assessments, interviews with 54 health providers, 148 structured observations of client-provider interactions, and 356 exit interviews with mothers of infants less than 10 weeks old (including 114 self-reported HIV-positive mothers) at the postnatal clinic.

Current Postnatal Services

The baseline study found that most health providers recommended the first postnatal care visit at six weeks, which was expected in light of the established guidelines. The majority of postpartum mothers interviewed (89 percent) were given a date for a six-week check-up before they left the postnatal ward. But only half of the postpartum women interviewed reported that they did in fact visit six weeks after giving birth.

Most women reported that a health provider asked them to return for immunizations (83 percent), child growth monitoring (57 percent), and family planning (53 percent). They cited child immunizations (82 percent) and family planning (23 percent) as the main reasons they were attending the postnatal clinic on the day they were interviewed (multiple responses were recorded). In addition women came to the clinics because either the child or mother was sick (14 percent and 4 percent, respectively).

As part of the study, the research team assessed the quality of care given during postnatal visits through 48 client-provider observations. They found that few health providers (less than 4 percent) adequately asked the client about the history of the most recent delivery. For example, less than 2 percent of providers asked whether the client had experienced any problems since the birth, such as any heavy bleeding. The majority of health providers (92 percent) did not ask about any underlying conditions in the baby. Furthermore, providers carried out a physical assessment of the mother in only 28 percent of cases. They measured their clients’ blood pressure during 22 percent of the observations, and assessed anemia in 14 percent.

HIV Services for Women

More than nine out of ten women interviewed had received information about HIV during visits to the ANC clinic, and a similar proportion had specifically received information about the HIV test. The vast majority of women (88 percent) had been tested for HIV: 82 percent as part of ANC, 15 percent at a VCT center, 2 percent in the labor ward, and 2 percent in the postnatal ward.

Among the 114 mothers who shared that they were HIV-positive with interviewers, most (85 percent) had been given Nevirapine during ANC, and of these women, 87 percent swallowed the dose during labor (71 percent while in early labor). These findings suggest that PMTCT services are reaching the majority of women who need them.

Eighty percent of newborns born to HIV-positive women were given Nevirapine syrup: 60 percent at birth, 38 percent after one day, and 2 percent after two to three days. For the 22 babies who did not take the medicine, two mothers forgot to take the medicine to the hospital, one reported transport difficulties, 13 said they were not offered the medicine, and six gave no reason.

A little over a third (35 percent) of all HIV-positive women said that their health providers discussed cotrimoxazole prophylaxis for their infants at 4–6 weeks during ANC. Among these women, 15 babies had started the prophylaxis during the postnatal period.

In a high prevalence setting such as Swaziland, it is particularly important to offer information on care and support for HIV-positive women and their infants as part of comprehensive postnatal care. At baseline, less than half of HIV-positive women (41 percent) said that they had received information on where else they could go to get additional care and support. Among these women, more than half (54 percent) received this information from an ANC provider, 38 percent from an HIV counselor, and only a quarter from a postnatal care provider.

Health providers reported that they offered information during postnatal care visits to HIV-positive mothers. Yet, less than half (41 percent) advised mothers on regular monitoring of CD4 counts, a little more than a fourth (26 percent) counseled mothers on available support and the same percentage advised mothers on where to seek psychosocial support, and only 19 percent instructed mothers to bring their babies back for cotrimoxazole prophylaxis.

Next Steps

Findings from the baseline study, which point to important gaps in the provision of postnatal care to mothers in Swaziland, are being used to inform an ongoing intervention to operationalize the new guidelines, which is being implemented by the Elizabeth Glaser Pediatric AIDS Foundation and the BASICS project. The intervention offers competency-based training in maternal and newborn care, updates in PMTCT, support supervision, and job aids for health workers to facilitate implementation of the new postnatal package of care. The evaluation of the intervention will take place in mid-2007, after which the new postnatal guidelines will be finalized.

Return to Table of Contents | Next article >

See Also

FRONTIERS
Population Council Infants and Children
Population Council Journals and Newsletters
Population Council Prevention

For additional information please contact:
Horizons
Population Council
4301 Connecticut Ave. NW, Suite 280
Washington, DC 20008
Telephone: +1 202 237 9400
Facsimile: +1 202 237 8410
E-mail: horizons@popcouncil.org

Print this page

@
E-mail this page

This page updated
6 July 2007