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

The study was conducted in the Greater Accra Region of Ghana. The region has approximately 4 million inhabitants and accounts for 16% of Ghana’s population [18]. The region is predominately urban and represents the most educated and wealthiest segment of the population [9]. The government health system is organized within a three-tier framework, whereby basic obstetric care begins in primary and community health centers but may progress to district hospitals for emergency obstetric care, and finally to regional and teaching hospitals for the highest level of care for life threatening conditions [19].

Thirteen healthcare facilities in Greater Accra were included to assess the content and retention of postnatal counselling. The Greater Accra Regional Hospital (GARH) was selected as a major obstetric referral hospital, as well as 4 district and 8 sub-district level facilities within the referral cluster. Facility assessments were initially conducted to determine the number of deliveries, cesarean delivery rate, number of midwives and PNC specific nurses, frequency of staff rotations, timing of discharge following vaginal or cesarean delivery and the schedule of PNC visits. A clinically practicing midwife from GARH, familiar with PNC requirements, was recruited and trained to administer postpartum patient and staff surveys to gain an understanding of the postnatal education format, timing and content.

Interviews were conducted among postpartum women who had delivered within a selected facility within the previous 72 h. Patients were included if they had experienced a live birth (vaginal or operative), were in good health, and were awaiting imminent facility discharge. Patients were excluded if they were in poor health or they were being discharged without their newborn. Following verbal consent and prior to hospital discharge, a structured questionnaire was administered in a semi-private setting by the trained nurse in the local dialect (Supplement 1 Exit Interview for PNC Mothers). An oral format was used to reduce potential barriers of illiteracy and lack of familiarity with medical terminology. Questions included age, parity, name of delivery facility, whether the patient had been informed about the importance of postnatal care during an antenatal visit, the postnatal counseling format, what information was provided, to whom, the number and timing of follow-up postnatal visits, what maternal and newborn danger signs and other conditions to be aware of, whether a contact phone number was given and suggestions for improvement. Participation was voluntary and patient anonymity was maintained.

During the same time intervals, key informants from each health facility were interviewed regarding their views of the postnatal educational process (Supplement 2 Interview for PNC Providers). Informants included various grades of midwives or nurses who were in positions of leadership within their facilities and familiar with the postpartum educational process. Questions addressed the availability of PNC guidelines, adherence to the guidelines, the educational format used, the schedule for PNC visits, whether mothers were encouraged to call for questions or concerns, what barriers or challenges are faced, and what strategies or interventions could improve the process.

Facility assessments were conducted March 8–21, 2017. The number of deliveries at each facility was collected for the previous 2 years. The average number of deliveries and staffing characteristics across facility types are shown in Table 1. Cesarean deliveries were only conducted in regional and district hospitals. Every regional and district level hospital had dedicated postnatal nurses, but in three of the eight sub-district level hospitals, the same labor ward midwifes doubled as postnatal nurses. In all of the district hospitals, staff rotation occurred annually, except in one facility where rotation occurred biennially. In sub-district level hospitals, rotation of staff occurred annually in five hospitals and did not occur in three hospitals nor did it occur at the regional hospital. Regarding timing of discharge, in the regional hospital, discharge occurred 12–24 h after vaginal delivery and 2–3 days after operative delivery for low risk women. In the district hospitals, the timing of patient discharge occurred 6 h after vaginal delivery in the three higher volume (> 3000 deliveries) and 24 h after vaginal delivery in the one lower volume (< 2000 deliveries) hospital. For operative delivery, two district hospitals discharged patients after 48 h and two after 72 h of delivery. For sub-district level hospitals, patients were discharged 6 h following vaginal delivery in three hospitals and at 24 h in five hospitals, without regard to delivery volume.

Between August 30, 2017 and November 28, 2017, 172 structured postnatal patient interviews were conducted in the 13 selected health facilities in the Greater Accra region. There were 21 (12%) interviews at the regional hospital, 68 (39%) at four district hospitals and 83 (48%) at eight sub-district level hospitals. Overall, fifty-eight (34%) interviews were done for new mothers. Patient demographic and educational level data within hospital categories is shown in Table 2. Over half (57%) the patients were made aware of the need for PNC during their ANC visits and this was similar across hospital types (Table 3). The majority of women received PNC education in a group setting, although district and sub-district level hospitals conducted some one-on-one counseling. Family members or other support persons were infrequently involved in the pre-discharge education process (Table 3). Across hospital types, more mothers stated that they were informed about the PNC visit schedule than could recall it; however, mothers in the sub-district hospitals were significantly more likely to know the correct number of recommended PNC visits and the schedules than were the patients in the regional or district hospitals (p < 0.01; Table 3). Only 39 (23%) of the interviewed women stated that they were given a phone number or contact to call if they had questions or concerns following discharge and this was similar across hospitals. Two women, both in sub-district level hospitals, stated that they did not receive PNC instructions. Both were aware of the need for PNC but only one stated she was given a contact number to call for questions.

Mothers were asked if specific content areas were addressed in their pre-discharge instructions (Fig. 1). Responses were uniformly high on the topics of cord care, breastfeeding and personal hygiene. Other subject content areas were consistently lower, apart from maternal danger signs, which were significantly more likely to be discussed with mothers in the regional hospital (p = 0.02; Fig. 1). Consistently, women who delivered in the regional hospital were significantly more likely to recall specific maternal danger signs than were the women who delivered in district and sub-district facilities (p < 0.01 value; Table 4). Danger signs were described as conditions in which the mother should report back to the hospital. Overall, women identified 13 maternal danger signs, the leading five of which were: vaginal bleeding (n = 92; 53%), malaise (n = 48; 28%), dizziness (n = 38; 22%), pain (n = 36; 21%), and headache (n = 28; 16%). Thirty-nine (28%) women reported that they were not informed about maternal danger signs. Similarly, mothers described 18 separate newborn danger signs, the leading five of which were: jaundice (n = 77; 45%), fever (n = 56; 33%), lethargy (n = 40; 23%), rash (n = 24; 14%), and cord problems (n = 23; 13%). Thirty-one mothers (18%) were unable to name any newborn danger signs. No mother recalled more than four maternal and five newborn danger signs.

Mothers were additionally asked if they were instructed on how to identify important postpartum conditions. Women in regional hospitals were significantly more likely to have received information about recognizing breast problems, signs of maternal infection and postpartum hypertension (p < 0.05; Fig. 2); however, the overall rates of information sharing on common complications was low. When mothers were asked the minimum recommended time that newborns be exclusively breastfed, 95% reported 6 months with response rates high among facilities. Eighty-eight percent of mothers felt that their questions and concerns were addressed and this was consistent across facilities. Similarly, mothers graded the adequacy of their postnatal information as 4.2 on a five-point Likert scale (1 = very inadequate, 2 = inadequate, 3 = average, 4 = adequate, 5 = very adequate) with little variation across facility type. When asked what could be improved, 135 (78%) of women had nothing to add; however, eleven specific suggestions were made. In order of frequency, women recommended: more emphasis on danger signs (7), having a ANC/PNC school (6), improving staff relations (6), one-on-one education (4), sex education/family planning (4), breastfeeding education (3), having a take home checklist (2), having a PNC schedule (2), clearer language (1), advice on medical bills/finance (1), and providing all information at one time (1). Responses among women were compared in facilities that reported conducting discharge at six versus 24 h following routine vaginal delivery. There were no differences in responses with regards to the counseling format utilized, instruction received on maternal and newborn danger signs or family planning. Women discharged from facilities practicing early discharge more frequently reported having a family member present during PNC counseling (p = .04) whereas women discharged from facilities at 24 h were more likely to recall maternal danger signs (p = 0.05).

A healthcare provider from 12 of the 13 facilities was also surveyed to gauge their perceptions of postnatal counseling; one district hospital did not participate. Of the 12 providers, four were principle midwifery officers, three were principle nursing officers, three were senior midwifery officers and two were senior staff midwives. Healthcare providers were asked if they had written PNC educational guidelines; five (42%) reported that they did not have written guidelines including one district and four sub-district facilities. In facilities with guidelines, three respondents felt there was room for improvement. When asked what type of counseling format was provided, 83% responded that both a combined group and one-on-one format was provided and 17% reported group sessions only. Sixty-seven percent of interviewed staff recalled the recommended schedule for PNC visits; the regional hospital, one district and 2 sub-district facility respondents could not. Most staff indicated PNC was recommended at one- and six-weeks following delivery; however, there was inconsistency recalling the number and timing of visits within the first 72 h.

All providers indicated that they allowed questions from mothers during counselling sessions and 83% encouraged mothers to call following discharge for any challenges or concerns. Eighty-three percent of providers reported positive views toward the level of PNC education they provided and two facilities (17%), including one district and one sub-district facility, perceived a need for improvement. Only one sub-district provider thought that the information given to mothers was inadequate. The providers were asked what barriers were faced in educating mothers in an open-ended format as well as strategies they would recommend for improvement. The responses were organized into categories based on three themes: language differences (58%), personal issues (33%) such as “patients will do what they want regardless of counseling”, and a lack of written guidelines to follow (17%). When asked to make recommendations to improve PNC counselling, five themes emerged from the providers’ responses: adding take-home material for mothers (33%), establishing standard guidelines (33%), involving relatives in postnatal care visits (25%), giving demonstrations during counselling (17%), and increasing follow-up visits (17%).