What can we learn about postnatal care in Ghana if we ask the right questions? A qualitative study

How does social desirability bias influence survey-based estimates of the use of antenatal care in rural Nepal? A validation study

OBJECTIVES

Social desirability bias is often speculated to influence survey responses but seldom studied in healthcare. The objective was to explore whether social desirability scores (SDS) or the presence of interview observers is associated with inaccurate recall and overestimation of antenatal care (ANC) services.

DESIGN

Longitudinal validation study comparing recalled receipt of ANC services and nutrition components of ANC against direct observations of care. An adapted short form Marlowe-Crowne questionnaire was used to generate an SDS, and the presence of interview observers was treated as a separate exposure. We assessed accuracy and overestimation of recalled receipt of ANC services against observed receipt using log-binomial regression, adjusting for age, education, first-pregnancy and socioeconomic status.

SETTING

Rural Southern Nepal with recruitment from five government health posts.

PARTICIPANTS

401 pregnant women.

RESULTS

Social desirability scores did not significantly predict accuracy or overestimation of most types of ANC care except counselling on nausea. Higher SDS was associated with more accurate recall (adjusted RR, aRR 1.08 (95% CI 1.03, 1.12)) and less overestimation (aRR 0.85 (0.80, 0.91)). The presence of mothers-in-law or husbands during interviews was associated with greater overestimation of the number of ANC visits received by more than three visits (aRR 2.07 (1.11, 3.84)) and (aRR 4.19 (2.17, 8.10)), respectively. Those interviewed with friends present tended to overestimate the receipt of counselling on nausea, avoiding alcohol and not smoking.

CONCLUSION

The presence of observers can lead to overestimation of the receipt of ANC care and support the conduct of interviews in private settings despite challenges of doing so in village contexts. Findings that the SDS did not predict the accuracy of most types of ANC care might reflect a reality that such questions may not be sensitive from a social-norms perspective. Additional local adaptation of SDS is recommended.

Postpartum care needs assessment: women's understanding of postpartum care, practices, barriers, and educational needs

BACKGROUND

Complications in the postpartum period pose substantial risks to women and can result in significant maternal morbidity and mortality. However, there is much less attention on postpartum care compared to pregnancy and childbirth. The goal of this study was to gather information on women's knowledge of postpartum care and complications, recovery practices after childbirth, perceived barriers to receiving care during the postpartum period, and educational needs in four health centers. The findings can inform the development of appropriate curriculum and interventions for postnatal care education in similar settings.

METHODS

A descriptive qualitative study design was employed. Eight focus group discussions were conducted among 54 postpartum women who delivered in four health centers in Sagnarigu District in Tamale, Ghana. Audio recordings of focus group data were transcribed and translated, and thematic analysis was conducted.

RESULTS

There were six main themes that emerged from the focus group discussions: 1) baby focused postpartum care; 2) postpartum practices; 3) inadequate knowledge ofpostpartum danger signs; 4) barriers to accessing postpartum care 5) experiences of poor mental health; and 6) need for postpartum education.

CONCLUSIONS

Postpartum care for women in this study was primarily perceived as care of the baby post-delivery and missing key information on physical and mental health care for the mother. This can result in poor adjustment postpartum and critically, a lack of knowledge on danger signs for common causes of morbidity and mortality in the postpartum period. Future research needs to understand how to communicate important information on postpartum mental and physical health to better protect mothers in the region.

Effectiveness of adjunct telephone-based postnatal care on maternal and infant illness in the Greater Accra Region, Ghana: a randomized controlled trial

Introduction

Globally, postnatal care (PNC) is fraught with challenges. Despite high PNC coverages in Ghana’s Greater Accra Region (GAR), maternal and newborn health outcomes are of great concern. In 2017, neonatal and post-neonatal mortality rates in GAR were 19 and 13 per 1000 live births respectively despite PNC coverages of 93% for at least one PNC and 87.5% for PNC within 48 hours post-delivery. Telephone follow-up has been used to improve health outcomes in some settings, however, its usefulness in improving maternal and infant health during the postnatal period is not well known in Ghana. We assessed effectiveness of telephone-based PNC on infant and maternal illness in selected hospitals in GAR.

Methods

An open-label, assessor-blinded, parallel-group, two-arm superiority randomized controlled trial with 1:1 allocation ratio was conducted from September 2020 to March 2021. Mother-baby pairs in intervention arm, in addition to usual PNC, received midwife-led telephone counselling within 48 hours post-discharge plus telephone access to midwife during postnatal period. In control arm, only usual PNC was provided. Descriptive and inferential data analyses were conducted to generate frequencies, relative frequencies, risk ratios and 95% confidence intervals. Primary analysis was by intention-to-treat (ITT), complemented by per-protocol (PP) analysis.

Results

Of 608 mother-baby pairs assessed for eligibility, 400 (65.8%) were enrolled. During 3 months follow-up, proportion of infants who fell ill was 62.5% in intervention arm and 77.5% in control arm (p = 0.001). Maternal illness occurred in 27.5% of intervention and 38.5% of control participants (p = 0.02). Risk of infant illness was 20% less in intervention than control arm in both ITT analysis [RR = 0.8 (95%CI = 0.71–0.92] and PP analysis [RR = 0.8 (95%CI = 0.67–0.89)]. Compared to controls, risk of maternal illness in intervention arm was 30% lower in both ITT [RR = 0.7 (95%CI = 0.54–95.00)] and PP analysis [RR = 0.7 (95%CI = 0.51–0.94)].

Conclusion

Telephone-based PNC significantly reduced risk of maternal and infant illness within first 3 months after delivery. This intervention merits consideration as a tool for adoption and scale up to improve infant and maternal health.

Trial registration

This trial was retrospectively registered with the International Standard Randomized Controlled Trial Number (ISRCTN) Registry with number ISRCTN46905855 on 09/04/2021.

Discharge instructions given to women following delivery by cesarean section in Sub-Saharan Africa: A scoping review

OBJECTIVE

A scoping review of discharge instructions for women undergoing cesarean section (c-section) in sub-Saharan Africa (SSA).

METHOD

Studies were identified from PubMed, Globus Index Medicus, NiPAD, EMBASE, and EBSCO databases. Eligible papers included research based in a SSA country, published in English or French, and containing information on discharge instructions addressing general postnatal care, wound care, planning of future births, or postpartum depression targeted for women delivering by c-section. For analysis, we used the PRISMA guidelines for scoping reviews followed by a narrative synthesis. We assessed quality of evidence using the GRADE system.

RESULTS

We identified 78 eligible studies; 5 papers directly studied discharge protocols and 73 included information on discharge instructions in the context of a different study objective. 37 studies addressed wound care, with recommendations to return to a health facility for dressing changes and wound checks between 3 days to 6 weeks. 16 studies recommended antibiotic use at discharge, with 5 specifying a particular antibiotic. 19 studies provided recommendations around contraception and family planning, with 6 highlighting intrauterine device placement immediately after birth or 6-weeks postpartum and 6 studies discussing the importance of counselling services. Only 5 studies provided recommendations for the evaluation and management of postpartum depression in c-section patients; these studies screened for depression at 4-8 weeks postpartum and highlighted connections between c-section delivery and the loss of self-esteem as well as connections between emergency c-section delivery and psychiatric morbidity.

CONCLUSION

Few studies in SSA directly examine discharge protocols and instructions for women following c-section. Those available demonstrate wide variation in recommendations. Research is needed to develop structured evidence-based instructions with clear timelines for women. These instructions should account for financial burden, access to resources, and education of patients and communities.

Household Survey Measurement of Newborn Postnatal Care: Coverage, Quality Gaps, and Internal Inconsistencies in Responses

Reliable measurement of postnatal content of care is currently lacking despite the critical importance of care in this vulnerable period. We found that there is a large quality-coverage gap with missed opportunities for quality care as well as internal inconsistencies in responses to newborn questions.

Background:

Reliable measurement of newborn postnatal care is essential to understand gaps in coverage and quality and thereby improve outcomes. This study examined gaps in coverage and measurement of newborn postnatal care in the first 2 days of life.

Methods:

We analyzed Demographic and Health Survey data from 15 countries for 71,366 births to measure the gap between postnatal contact coverage and content coverage within 2 days of birth. Coverage was a contact with the health system in the first 2 days (postnatal check or newborn care intervention), and quality was defined as reported receipt of 5 health worker-provided interventions. We examined internal consistency between interrelated questions regarding examination of the umbilical cord.

Results:

Reported coverage of postnatal check ranged from 13% in Ethiopia to 78% in Senegal. Report of specific newborn care interventions varied widely by intervention within and between countries. Quality-coverage gaps were high, ranging from 26% in Malawi to 89% in Burundi. We found some internally inconsistent reporting of newborn care. The percentage of women who reported that a health care provider checked their newborn's umbilical cord but responded “no” to the postnatal check question was as high as 16% in Malawi.

Conclusion:

Reliable measurement of coverage and content of early postnatal newborn care is essential to track progress in improving quality of care. Postnatal contact coverage is challenging to measure because it may be difficult for women to distinguish postnatal care from intrapartum care and it is a less recognizable concept than antenatal care. Co-coverage measures may provide a useful summary of contact and content, reflecting both coverage and an aspect of quality.

Community- based maternal and newborn interventions in Africa: Systematic review

AIM AND OBJECTIVES

This review analysed the implementation and integration into healthcare systems of maternal and newborn healthcare interventions in Africa that include community health workers to reduce maternal and newborn deaths.

BACKGROUND

Most neonatal deaths (99%) occur in low- and middle-income countries, with approximately half happening at home. In resource-constrained settings, community-based maternal and newborn care is regarded as a sound programme for improving newborn survival. Health workers can play an important role in supporting families to adopt sound health practices, encourage delivery in healthcare facilities and ensure timeous referral. Maternal and newborn mortality is a major public health problem, particularly in sub-Saharan Africa, where the Millennium Development Goals 4, 5 and 6 were not achieved at the end of 2015.

METHODS

The review includes quantitative, qualitative and mixed-method studies, with a data-based convergent synthesis design being used, and the results grouped into categories and trends. The review took into account the participants, interventions, context and outcome frameworks (PICO), and followed the adapted PRISMA format for reporting systematic reviews of the qualitative and quantitative evidence guide checklist.

RESULTS

The results from the 17 included studies focused on three themes: antenatal, delivery and postnatal care interventions as a continuum. The main components of the interventions were inadequate, highlighting the need for improved planning before each stage of implementation. A conceptual framework of planning and implementation was elaborated to improve maternal and newborn health.

CONCLUSION

The systematic review highlight the importance of thoroughly planning before any programme implementation, and ensuring that measures are in place to enable continuity of services.

RELEVANT TO THE CLINICAL PRACTICE

Conceptual framework of planning and implementation of maternal and newborn healthcare interventions by maternal community health workers.

Postnatal care education in health facilities in Accra, Ghana: perspectives of mothers and providers

Background

The recent use of antenatal care (ANC) has steadily improved in low- and middle-income countries (LMIC), but postnatal care (PNC) has been widely underutilized. Most maternal and newborn deaths occur during the critical postnatal period, but PNC does not receive adequate attention or support, particularly in Sub-Saharan Africa. In Ghana, the majority of mothers attend four ANC assessments, but far fewer receive the four recommended PNC visits. This study sought to understand perceptions toward PNC counselling administered prior to discharge among both mothers and healthcare providers in the Greater Accra Region of Ghana.

Methods

Facility assessments were conducted among 13 health facilities to determine the number and type of deliveries, staffing, timing of discharge following delivery and the PNC schedule. Structured interviews were conducted for 172 mothers over four-months in facilities, which included one regional hospital, four district hospitals, and eight sub-district level hospitals. Additionally, healthcare providers from 12 of the 13 facilities were interviewed. Data were analyzed with Chi-square or students t-test, as appropriate, with p < 0.05 considered statistically significant.

Results

Ninety-nine percent of mothers received PNC instructions prior to hospital discharge, the majority of which were given in a group format. Mothers in the regional hospital were significantly more likely to have been informed about maternal danger signs but were less likely to know the PNC schedule than were mothers in district and sub-district facilities. No mother recalled more than four maternal or five newborn danger signs. Thirty-eight percent of facilities did not have PNC guidelines. Most patient and providers reported positive attitudes toward the level of PNC education, however, knowledge was inconsistent regarding the number and timing of PNC visits as well as other critical information. Only 23% of patients reported having a contact number to call for concerns.

Conclusions

Despite overall positive feelings toward PNC among Ghanaian mothers and providers, there are significant gaps in PNC education that must be addressed in order to recognize problems and to prevent serious complications. Improvements in pre-discharge PNC counseling should be provided in Ghana to give mothers and babies a better chance at survival in the critical postnatal period.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-020-03365-1.

What is meant by validity in maternal and newborn health measurement? A conceptual framework for understanding indicator validation

BACKGROUND

Rigorous monitoring supports progress in achieving maternal and newborn mortality and morbidity reductions. Recent work to strengthen measurement for maternal and newborn health highlights the existence of a large number of indicators being used for this purpose. The definitions and data sources used to produce indicator estimates vary and challenges exist with completeness, accuracy, transparency, and timeliness of data. The objective of this study is to create a conceptual overview of how indicator validity is defined and understood by those who develop and use maternal and newborn health indicators.

METHODS

A conceptual framework of validity was developed using mixed methods. We were guided by principles for conceptual frameworks and by a review of the literature and key maternal and newborn health indicator guidance documents. We also conducted qualitative semi-structured interviews with 32 key informants chosen through purposive sampling.

RESULTS

We categorised indicator validity into three main types: criterion, convergent, and construct. Criterion or diagnostic validity, comparing a measure with a gold standard, has predominantly been used to assess indicators of care coverage and content. Studies assessing convergent validity quantify the extent to which two or more indicator measurement approaches, none of which is a gold-standard, relate. Key informants considered construct validity, or the accuracy of the operationalisation of a concept or phenomenon, a critical part of the overall assessment of indicator validity.

CONCLUSION

Given concerns about the large number of maternal and newborn health indicators currently in use, a more consistent understanding of validity can help guide prioritization of key indicators and inform development of new indicators. All three types of validity are relevant for evaluating the performance of maternal and newborn health indicators. We highlight the need to establish a common language and understanding of indicator validity among the various global and local stakeholders working within maternal and newborn health.

Breastfeeding and caring for children: a qualitative exploration of the experiences of mothers with physical impairments in Ghana

Background

Breastfeeding and caring for children demand time, energy and effort. Mothers with physical impairments in Ghana require special needs to be able to achieve optimal motherhood as society demands. Globally, literature on breastfeeding and caring for children among mothers with physical disabilities is limited. Similarly, there is dearth of literature on the experiences of mothers with physical impairments in Ghana. Therefore, this study sought to add to literature by exploring the experiences of mothers with physical impairments with regards to breastfeeding and how they care for their children.

Methods

Qualitative descriptive exploratory design was used. Twelve mothers with physical impairments who had been purposively sampled gave informed consent before data was collected through in-depth one-on-one interviews. Data was recorded, transcribed and analyzed inductively using the content analysis technique.

Results

Mothers with physical impairments perceived breastfeeding as difficult and expensive due to issues relating to disruption of sleep, dysfunctional limbs and the need for breastfeeding mothers to eat nutritionally balanced meals. Participants felt prejudged and discriminated at different points in their daily encounters.

Conclusion

Mothers with physical impairments have challenges. Therefore, attitudinal change should be advocated in the Ghanaian society with respect to issues concerning people living with disabilities.

Discordance in postnatal care between mothers and newborns: Measurement artifact or missed opportunity?

Background

Postnatal care (PNC) for mothers and newborns is essential to monitor risks of morbidity and adverse conditions following delivery. Current estimates of the coverage of PNC show substantial discordance between mothers and newborns. We investigate the sources of this discordance in Demographic and Health Surveys (DHS).

Methods

We used DHS data from 48 countries collected since 2011, spanning phases 6 and 7 of the survey program with 32 and 16 surveys, respectively, analyzed. We assessed the distribution of the reported timing of PNC and conducted a sensitivity analysis that excludes/includes PNC reported within 0-1 hour or PNC in the day 2. Agreement in PNC reporting considered four groups: (1) Concordance, neither mother nor newborn received PNC; (2) Concordance, mother and newborn pair received PNC; (3) Discordance, mother received PNC and newborn did not; of (4) Discordance, mother did not receive PNC but the newborn did. We carried out logistic regressions to understand correlates of PNC discordance. All analyses distinguished phase 6 surveys from phase 7.

Results

We found substantial differences in the PNC coverage estimated between phase 6 and phase 7 surveys. The phase 7 PNC questions for newborns were improved to increase the understanding of the questions by respondent which probably led to reducing the large PNC gap between mothers and newborns observed in phase 6 surveys. With phase 6 surveys, PNC coverage for mother was estimated on average at 62% compared to only 31% for newborns. No such gap was observed for phase 7 surveys, where for both mothers and newborns, the PNC coverage estimate was similar, at 56%. For both phases, over half of the reported PNC for mothers and newborns occurred during 0-1 hour following delivery, leading to substantial overestimation of PNC coverage, due to confusion between intrapartum care and PNC. There were 37% discordant cases between mother and newborn, largely in favor of the mother in phase 6 surveys, compared to 16% in phase 7 surveys. In phase 6 surveys, discordant PNC cases were observed largely among facility deliveries vs non-facility deliveries (44% compared to 19%).

Conclusions

Current estimates of coverage of PNC from DHS phase 6 surveys appears to include substantial level of measurement noises that could explain substantial part of the mother-newborn discordance in PNC. The PNC estimates appear to capture a substantial number of intrapartum care. Current measurement approaches warrant further validation to ensure accurate monitoring of the PNC programs.

'I am still confused as to what caused the problem': Perceptions of mothers on communication regarding newborn illness and death in Northern Ghana

Neonatal morbidity and mortality remain a significant challenge in Ghana. Given the relationship between care-seeking and understanding of illness, this study aimed to explore mothers' perceptions of the cause of illness and/or death in Northern Ghana. All neonatal deaths and near-misses (babies who survived a life-threatening complication) in 2015 and 2016 were identified through a community - and facility-based surveillance system. Mothers of the deceased or ill infants participated in open narrative qualitative interviews. Narratives that included discussion of whether the mother understood what caused the baby's illness or death were analysed. Interviews with 155 mothers included discussion of their perception of the cause of newborn illness or death. Of the 155 interviews, 108 interviews involved mothers whose babies died, and 47 interviews involved mothers whose newborns survived a life-threatening illness, a neonatal 'near-miss'. Very few expressed a clear understanding of the cause of death or illness. Those mothers who did not understand were either not told or did not understand the cause of illness or death. Newborn health outcomes may be improved by increased maternal awareness and understanding of neonatal illnesses. Future interventions need to address communication issues that impair mothers' understanding, facilitate recognition of danger signs, and prompt timely care-seeking.

Home visits by community health workers for pregnant mothers and newborns: coverage plateau in Malawi

BACKGROUND

Home visits by community health workers (CHWs) during pregnancy and soon after delivery are recommended to improve newborn survival. However, as the roles of CHWs expand, there are concerns regarding the capacity of community health systems to deliver high effective coverage of home visits. The WHO's Rapid Access Expansion (RAcE) program supported the Malawi Ministry of Health to align their Community-Based Maternal and Newborn Care (CBMNC) package with the latest WHO guidelines and to implement and evaluate the feasibility and coverage of home visits in Ntcheu district.

METHODS

A population-based survey of 150 households in Ntcheu district was conducted in July-August 2016 after approximately 10 months of CBMNC implementation. Thirty clusters were selected proportional-to-size using the most recent census. In selected clusters, five households with mothers of children under six months of age were randomly selected for interview. The Health Surveillance Assistants (HSAs) providing community-based services to the same clusters were purposively selected for a structured interview and register review.

RESULTS

Less than one third of pregnant women (30.7%; 95% confidence interval CI = 21.7%-41.5%) received a home visit during pregnancy and only 20.7% (95% CI = 13.0%-29.4%) received the recommended two visits. Coverage of postnatal visits was even lower: 11.4% (95%CI = 6.8%-18.5%) of mothers and newborns received a visit within three days of delivery and 20.7% (95%CI = 12.7%-32.0%) received a visit within the first eight days. Reaching newborns soon after delivery requires timely participation of the family and/or health facility staff to notify the HSA - yet only 42.9% (95% CI = 33.4%-52.9%) of mothers reported that the HSA was informed of the delivery. Coverage of postnatal home visits among those who informed the HSA was significantly higher than among those in which the HSA was not informed (46.7% compared to 1.3%; P = 0.00). Most HSAs had the necessary equipment and supplies and were active in CBMNC: 83.9% (95% CI = 70.2%-97.6%) of HSAs had pregnancy home visits and 77.4% (95% CI = 61.8%-93.0%) had postnatal home visits documented in their registers for the previous three months.

CONCLUSIONS

We found low coverage of home visits during pregnancy and soon after delivery in a well-supported program delivery environment. Most HSAs were conducting home visits, but not at the level needed to reach high coverage. These findings were similar to previous studies, calling into question the feasibility of the current visitation schedule. It is time to re-align the CBMNC package with what the existing platform can deliver and identify strategies to better support HSAs to implement home visits to those who would benefit most.

Maternal postnatal care in Bangladesh: a closer look at specific content and coverage by different types of providers

Background

The first 48 hours after birth is a critical window of time for the survival for both mothers and their newborns. Timely and adequate postnatal care (PNC) is being promoted as a strategy to reduce both maternal and newborn mortality. Whether or not a woman has received a postnatal check within 48 hours has been well studied, however, specific content and type of provider are also important for understanding the quality of the check. The objective of this paper is to understand who receives specific PNC interventions by type of provider in Bangladesh.

Methods

Data from the 2014 Bangladesh Demographic and Health Survey (DHS) were used to study receipt of specific PNC interventions - breast exam, vaginal discharge exam, temperature check and counseling on danger signs - within 2 days of birth. Descriptive bivariate analyses and regression analyses using generalized estimating equations (GEE) were used to understand if receipt of an intervention differed by socio-economic and health-related factors. A key factor studied was the type of provider of the PNC.

Results

The proportion of women receiving specific interventions during maternal PNC was mostly low (41.81% for breast exam, 39.72% for vaginal discharge, 82.22% for temperature check, 55.56% for counseling on danger signs and 16.95% for all four interventions). Findings from the regression analyses indicated that compared to having postnatal contact with formal providers (doctors, nurses, midwives and paramedics), having postnatal contact with village doctors was significantly associated with lower probabilities of receiving a breast exam, vaginal discharge exam and receiving all four interventions. PNC provided by NGO workers and other community attendants was significantly associated with a lower probability of receiving a vaginal discharge exam but a higher probability of receiving counseling on danger signs.

Conclusions

During PNC, women were much more likely to receive a temperature check than counseling on danger signs, breast exams or vaginal discharge exams. Very few women received all four interventions. In the situation where Bangladesh is experiencing a shortage of high-level providers, training more types of providers, particularly informal village doctors, may be an important strategy for improving the quality of PNC.

Postnatal care in Rwanda: facilitators and barriers to postnatal care attendance and recommendations to improve participation

Background

Sub-Saharan Africa has the highest rates of neonatal mortality in the world with an estimated 1.2 million deaths within the first 28 days of life. Postnatal care (PNC) can contribute to reductions in morbidity and mortality in mothers and newborns through vital support that identifies danger signs and establishes valuable practices and referral processes.

Methods

This qualitative data was collected as a part the East Africa Preterm Birth Initiative (PTBi-EA) to guide development of a group antenatal (ANC) and PNC model in Rwanda. Key-informant in-depth interviews (IDIs) and focus group discussions (FGDs) were conducted in four districts. Sixteen FGDs with 180 participants and 22 IDIs were completed at the time of thematic saturation.

Results

Four themes highlighted facilitators and barriers to PNC attendance and recommendations to improve participation: 1) There is little awareness in the community of what the PNC package is; PNC 4 in particular is not well understood; 2) PNC visits by community health workers (CHWs) are well accepted and valued; 3) Providers perceive PNC 4 as an added burden to an already high workload; 4) Community structures exist to better disseminate key messages about PNC, but have not yet been effectively utilized.

Conclusions

This qualitative work provides evidence that the PNC package was not initially well understood. Regardless, PNC service delivery performed by CHWs in Rwanda is well accepted and appreciated by the population, providing assurance that the full package has potential to be well utilized and valued by the population.

Validation studies for population-based intervention coverage indicators: design, analysis, and interpretation

Background

Population-based intervention coverage indicators are widely used to track country and program progress in improving health and to evaluate health programs. Indicator validation studies that compare survey responses to a “gold standard” measure are useful to understand whether the indicator provides accurate information. The Improving Coverage Measurement (ICM) Core Group has developed and implemented a standard approach to validating coverage indicators measured in household surveys, described in this paper.

Methods

The general design of these studies includes measurement of true health status and intervention receipt (gold standard), followed by interviews with the individuals observed, and a comparison of the observations (gold standard) to the responses to survey questions. The gold standard should use a data source external to the respondent to document need for and receipt of an intervention. Most frequently, this is accomplished through direct observation of clinical care, and/or use of a study-trained clinician to obtain a gold standard diagnosis. Follow-up interviews with respondents should employ standard survey questions, where they exist, as well as alternative or additional questions that can be compared against the standard household survey questions.

Results

Indicator validation studies should report on participation at every stage, and provide data on reasons for non-participation. Metrics of individual validity (sensitivity, specificity, area under the receiver operating characteristic curve) and population-level validity (inflation factor) should be reported, as well as the percent of survey responses that are “don’t know” or missing. Associations between interviewer and participant characteristics and measures of validity should be assessed and reported.

Conclusions

These methods allow respondent-reported coverage measures to be validated against more objective measures of need for and receipt of an intervention, and should be considered together with cognitive interviewing, discriminative validity, or reliability testing to inform decisions about which indicators to include in household surveys. Public health researchers should assess the evidence for validity of existing and proposed household survey coverage indicators and consider validation studies to fill evidence gaps.

Program assessment of efforts to improve the quality of postpartum counselling in health centers in Morogoro region, Tanzania

BACKGROUND

The postpartum period represents a critical window where many maternal and child deaths occur. We assess the quality of postpartum care (PPC) as well as efforts to improve service delivery through additional training and supervision in Health Centers (HCs) in Morogoro Region, Tanzania.

METHODS

Program implementers purposively selected nine program HCs for assessment with another nine HCs in the region remaining as comparison sites in a non-randomized program evaluation. PPC quality was assessed by examining structural inputs; provider and client profiles; processes (PNC counselling) and outcomes (patient knowledge) through direct observations of equipment, supplies and infrastructure (n = 18) and PPC counselling (n = 45); client exit interviews (n = 41); a provider survey (n = 62); and in-depth provider interviews (n = 10).

RESULTS

While physical infrastructure, equipment and supplies were comparable across study sites (with water and electricity limitations), program areas had better availability of drugs and commodities. Overall, provider availability was also similar across study sites, with 63% of HCs following staffing norms, 17% of Reproductive and Child Health (RCH) providers absent and 14% of those providing PPC being unqualified to do so. In the program area, a median of 4 of 10 RCH providers received training. Despite training and supervisory inputs to program area HCs, provider and client knowledge of PPC was low and the content of PPC counseling provided limited to 3 of 80 PPC messages in over half the consultations observed. Among women attending PPC, 29 (71%) had delivered in a health facility and sought care a median of 13 days after delivery. Barriers to PPC care seeking included perceptions that PPC was of limited benefit to women and was primarily about child health, geographic distance, gaps in the continuity of care, and harsh facility treatment.

CONCLUSIONS

Program training and supervision activities had a modest effect on the quality of PPC. To achieve broader transformation in PPC quality, client perceptions about the value of PPC need to be changed; the content of recommended PPC messages reviewed along with the location for PPC services; gaps in the availability of human resources addressed; and increased provider-client contact encouraged.

Women's recall of maternal and newborn interventions received in the postnatal period: a validity study in Kenya and Swaziland

Background

Despite the concentration of maternal and infant deaths in the early postnatal period, information on the content and quality of postnatal care interventions is not routinely collected in most low and middle-income countries. At present, data on the coverage of postnatal care interventions mostly rely on women’s reports collected in household surveys, such as the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), which collect limited information. We assessed the validity of a set of postnatal care indicators that reflect a range of recommended interventions for both mother and newborn and have potential to be included in household surveys for monitoring of population-level coverage.

Methods

We compared women’s reports in exit interviews on the content of postnatal care received in health facilities located in Kenya and Swaziland against a gold standard of direct observation by a trained third party. We calculated sensitivity, specificity and the area under the receiver operating curve (AUC) to assess individual-level reporting accuracy and the inflation factor (IF) to assess population-level accuracy. We also examined whether women’s reporting accuracy varied significantly by her sociodemographic characteristics.

Results

18 indicators in Kenya and 19 in Swaziland had sufficient sample size for analysis. Of these, 12 indicators in Kenya and five in Swaziland met criteria for acceptable individual and population-level reporting accuracy. Two indicators met acceptability criteria in both Kenya and Swaziland: whether the provider performed a breast exam or an abdominal exam. There was no significant association between women’s characteristics and reporting accuracy, across indicators.

Conclusion

Women are able to accurately report on multiple aspects of care received during a postnatal visit. Findings inform the recommendation of indicators for tracking progress of critical postnatal care interventions for mothers and newborns. Improved measurement of the coverage of maternal and newborn postnatal care is warranted to monitor progress in maternal and newborn care globally.

Postnatal care for newborns in Bangladesh: The importance of health-related factors and location

Background

Bangladesh achieved Millennium Development Goal 4, a two thirds reduction in under-five mortality from 1990 to 2015. However neonatal mortality remains high, and neonatal deaths now account for 62% of under-five deaths in Bangladesh. The objective of this paper is to understand which newborns in Bangladesh are receiving postnatal care (PNC), a set of interventions with the potential to reduce neonatal mortality.

Methods

Using data from the Bangladesh Maternal Mortality Survey (BMMS) 2010 we conducted logistic regression analysis to understand what socio-economic and health-related factors were associated with early postnatal care (PNC) by day 2 and PNC by day 7. Key variables studied were maternal complications (during pregnancy, delivery or after delivery) and contact with the health care system (receipt of any antenatal care, place of delivery and type of delivery attendant). Using data from the BMMS 2010 and an Emergency Obstetric and Neonatal Care (EmONC) 2012 needs assessment, we also presented descriptive maps of PNC coverage overlaid with neonatal mortality rates.

Results

There were several significant findings from the regression analysis. Newborns of mothers having a skilled delivery were significantly more likely to receive PNC (Day 7: OR = 2.16, 95% confidence interval (CI) 1.81, 2.58; Day 2: OR = 2.11, 95% 95% CI 1.76). Newborns of mothers who reported a complication were also significantly more likely to receive PNC with odds ratios varying between 1.3 and 1.6 for complications at the different points along the continuum of care. Urban residence and greater wealth were also significantly associated with PNC. The maps provided visual images of wide variation in PNC coverage and indicated that districts with the highest PNC coverage, did not necessarily have the lowest neonatal mortality rates.

Conclusion

Newborns of mothers who had a skilled delivery or who experienced a complication were more likely to receive PNC than newborns of mothers with a home delivery or who did not report a complication. Given that the majority of women in Bangladesh have a home delivery, strategies are needed to reach their newborns with PNC. Greater focus is also needed to reach poor women in rural areas. Engaging community health workers to conduct home PNC visits may be an interim strategy as Bangladesh strives to increase skilled delivery coverage.

Evidence from household surveys for measuring coverage of newborn care practices

BACKGROUND

Aside from breastfeeding, there are little data on use of essential newborn care practices, such as thermal protection and hygienic cord care, in high mortality countries. These practices have not typically been measured in national household surveys, often the main source for coverage data in these settings. The Every Newborn Action Plan proposed early breastfeeding as a tracer for essential newborn care due to data availability and evidence for the benefits of breastfeeding. In the past decade, a few national surveys have added questions on other practices, presenting an opportunity to assess the performance of early breastfeeding initiation as a tracer indicator.

METHODS

We identified twelve national surveys between 2005-2014 that included at least one indicator for immediate newborn care in addition to breastfeeding. Because question wording and reference populations varied, we standardized data to the extent possible to estimate coverage of newborn care practices, accounting for strata and multistage survey design. We assessed early breastfeeding as a tracer by: 1) examining associations with other indicators using Pearson correlations; and 2) stratifying by early breastfeeding to determine differences in coverage of other practices for initiators vs non-initiators in each survey, then pooling across surveys for a meta-analysis, using the inverse standard error as the weight for each observation.

FINDINGS

Associations between pairs of coverage indicators are generally weak, including those with breastfeeding. The exception is drying and wrapping, which have the strongest association of any two interventions in all five surveys where measured; estimated correlations for this range from 0.47 in Bangladesh's 2007 DHS to 0.83 in Nepal's 2006 DHS. The contrast in coverage for other practices by early breastfeeding is generally small; the greatest absolute difference was 6.7%, between coverage of immediate drying for newborns breastfed early compared to those who were not.

CONCLUSIONS

Early initiation of breastfeeding is not a high performing tracer indicator for essential newborn care practices measured in previous national surveys. To have informative data on whether newborns are getting life-saving services, standardized questions about specific practices, in addition to breastfeeding initiation, need to be added to surveys.

Barriers to utilization of postnatal care at village level in Klaten district, central Java Province, Indonesia

BACKGROUND

Maternal health remains a persisting public health challenge in Indonesia. Postnatal complications, in particular, are considered as maternal health problems priority that should be addressed. Conducting adequate care for postnatal complications will improve the quality of life of mothers and babies. With the universal health coverage implementation, the Indonesian government provides free maternal and child health services close to clients at the village level, which include postnatal care. Our study aimed to explore barriers to utilization of postnatal care at the village level in Klaten district, Central Java Province, Indonesia.

METHODS

A qualitative study was conducted in March 2015 - June 2016 in Klaten district, Central Java, Indonesia. We selected a total of 19 study participants, including eight mothers with postnatal complications, six family members, and five village midwives for in-depth interviews. We conducted a content analysis technique on verbatim transcripts of the interviews using open code software.

RESULTS

This study found three categories of barriers to postnatal care utilization in villages: mother and family members' health literacy on postnatal care, sociocultural beliefs and practices, and health service responses. Most mothers did not have adequate knowledge and skills regarding postnatal care that reflected how they lacked awareness and practice of postnatal care. Inter-generational norms and myths hindered mothers from utilizing postnatal care and from having adequate nutritional intake during the postnatal period. Mothers and family members conducted unsafe self-treatment to address perceived minor postnatal complication. Furthermore, social power from extended family influenced the postnatal care health literacy for mother and family members. Postnatal care in the village lacked patient-centered care practices. Additionally, midwives' workloads and capacities to conduct postnatal information, education and counseling were also issues.

CONCLUSIONS

Despite the government's efforts to provide free postnatal care closer to mothers' homes, other barriers to postnatal care utilization remained. Specifically, among mothers, community, and health services. An innovative approach to increase the health literacy on postnatal care is required. In particular, improving the capacity of midwives to conduct patient-centered care. In addition, village midwives' tasks should be evaluated and reoriented.