Background
Timing and recommended service content for routine postpartum care visits | |
1. ≤24 h after delivery: • Clinical assessment of mothers and newborns within an hour after birth; | |
• Infant feeding practices, skin-to-skin contact, and identification of danger signs for both mother and baby; | |
• Prior to facility discharge providers to give counseling on danger signs, nutrition, family planning, self-care for the mother and child at home, as well as preventive measures such as bed nets and a supply of iron and vitamin A to the mother. | |
2. ≤7 days after birth: provider follow up with mother and baby about danger signs and continue health education. | |
3. 28 days after the birth: child immunization and examinations to check for continued recovery of mother and healthy development of child. | |
4. 42 days after the birth: child immunization and examinations to check for continued recovery of mother and healthy development of child. | |
5. Reproductive Child Health follow-up care for 1 year postpartum | |
6. Maternal and/or baby consultations as needed in event of complications | |
Basic PPC Care Package in Tanzania | |
Providers should: | |
• Discuss breastfeeding, breast care or alternate infant feeding options for HIV-positive women; | |
• Emphasize the Lactational Amenorrhoea Method (LAM) and later transition to other family planning methods; | |
• Provide nutritional support; | |
• Counsel on self-care and other healthy practices; | |
• Discuss mother and baby danger signs; | |
• Make complication readiness plans; | |
• Offer HIV counseling and testing; | |
• Provide immunizations; | |
• Offer preventive measures (i.e., iron/folate supplements); | |
• Provide antiretroviral medicine and cotrimoxazole prophylaxis as needed. |
Assessing quality of postpartum care
Methods
Study site, design and sampling
Domains of Quality | Measurement Methods | Sampling | Final sample | |
---|---|---|---|---|
Structural inputs | Supply and infrastructure availability | Observations of infrastructure, drugs, supplies, and commodities | 100% of all health centers in 5 districts | 18 health centers: 9 program, 9 comparison |
Supervision | PPC provider survey | • Interview with facility in-charge to determine available human resources (n = 18) • Sub-sample health center RCH providers (n = 88) available on day of visit • Sub-analysis of RCH service providers that reported providing PPC services in the preceding 7 days | 18 health centers in-charges: 9 program, 9 comparison 62 PPC providers; 38 program area, 24 comparison | |
Provider profile | Health provider ability and availability | |||
Perceptions of PPC | Qualitative in-depth provider interviews | Sub-analysis of PPC providers interviewed as part of qualitative in-depth interviews carried out among 57 RCH providers (mean of 3 per facility) | 10 PPC Providers; 6 program area, 4 comparison | |
Client profile | • Social profile • Health profile | • Qualitative in-depth interviews • PPC client exit interviews | Of 45 PPC clients observed, 41 consented to exit interviews. | 41 completed exit interviews; 25 program area, 16 comparison |
Process | • PPC Counseling content • PPC Service accessibility and efficiency | Observations of PPC counseling sessions delivered | • Total approved target sample of 240 to detect a 30% difference (design effect of 2.0) in frequency of observed messages on postpartum family planning across study arms. Quota based on availability on day of visit. • 55 PPC Clients presented for services during 36 days of observation (2 days per facility). • Of 55 total PPC clients, 45 consented to observation; 9 departed prior to service delivery and 1 declined consent. | 45 completed observations; 26 program area, 19 comparison |
Outcome | Client knowledge | Quantitative PPC client exit interviews | Of 45 PPC clients observed, 41 consented to exit interviews. | 41 completed exit interviews; 25 program area, 16 comparison |
Data collection
Data analyses
Results
Structural inputs
Provider profiles
“But still the challenge is that there are few attendants…maybe at RCH perhaps people have arrived, maybe there are four for postpartum care, you need to thoroughly examine these [patients] and still there are pregnant women [coming for ANC visits]…so there comes the challenge to observe every aspect [of PPC].” (Registered nurse, 10 years of experience, PPC training)
Total | Program | Control | |
---|---|---|---|
All facility characteristicsa | |||
Median number of providers reported per facility | 24 | 28 | 21 |
Median number of providers reported providing MNCH per facility | 11 | 10 | 11 |
Median number of providers trained in PPC per facility | 1 | 4 | 0 |
Characteristics of interviewed RCH providers who reported providing PPC | (N = 63) | (N = 37) | (N = 26) |
Female provider | 49 (77%) | 28 (76%) | 21 (79%) |
Designation | |||
Enrolled Nurse | 32 (51%) | 19 (50%) | 15 (58%) |
Registered Nurse | 10 (16%) | 6 (16%) | 4 (15%) |
Medical Attendant | 9 (14%) | 7 (18%) | 2 (8%) |
Clinical officer/ Ass. Clinical officer | 5 (8%) | 3 (8%) | 2 (8%) |
Othera | 6 (10%) | 3 (8%) | 3 (12%) |
Years working as a health worker (Median) | 13 | 13 | 12.5 |
Years working in this health facility (Median) | 4 | 3 | 4.5 |
PPC providers whom have received PPC training | 18 (29%) | 17 (46%) | 1 (4%) |
Characteristics of interviewed RCH providers trained in PPC | (N = 19) | (N = 17) | (N) = 2 |
Female provider | 16 (84%) | 14 (82%) | 2 (100%) |
Designation | |||
Enrolled Nurse | 14 (74%) | 12 (71%) | 2 (100%) |
Registered Nurse | 4 (21%) | 4 (24%) | 0% |
Otherb | 1 (5%) | 1 (6%) | 0% |
Years working as a health worker (Median) | 17 | 15 | 29 |
Years working in this health facility (Median) | 4.3 | 4 | 15 |
“We were studying it at school, but after studying it, practicing it here in working stations was so minimal, only maybe there at the labor room after delivery after they have delivered.” (Enrolled nurse, 5 years of experience, no PPC training)
Client profiles
Total | Program | Comparison | |
---|---|---|---|
PPC Client Characteristics | N = 41 | N = 25 | N = 16 |
Age (median time in years) | 24 | 23 | 28 |
Health facility delivery | 29 (71%) | 14 (55%) | 12 (76%) |
Days since delivery (median) | 7.0 | 7.0 | 11 |
Mode of delivery | |||
Normal without episiotomy | 38 (93%) | 23 (92%) | 15 (94%) |
Normal with episiotomy | 2 (5%) | 1 (4%) | 1 (6%) |
Cesarean | 1 (2%) | 1 (4%) | 0 (0%) |
Years of Schooling | |||
No formal education | 14 (33%) | 12 (48%) | 2 (12%) |
Primary | 20 (48%) | 10 (40%) | 9 (59%) |
Secondary | 6 (14%) | 3 (12%) | 3 (18%) |
Others | 1 (2%) | 0 (0%) | 2 (12%) |
Number of times pregnant prior to delivery of last child (median) | 1.5 | 1.0 | 2.0 |
Patient recalled visit characteristics | N = 41 | N = 25 | N = 16 |
Duration of travel time to get health facility (median time in minutes) | 30 | 60 | 15 |
Duration of waiting time between arriving at clinic and being seen by provider (median time in minutes) | 30 | 30 | 15 |
Client perceptions on waiting time | |||
Long / too long | 17 (41%) | 11 (43%) | 6 (40%) |
Acceptable | 22 (53%) | 13 (52%) | 8 (53%) |
Short | 2 (6%) | 1 (5%) | 1 (7%) |
Reason for PPC Visit | |||
Baby well-visit | 25 (61%) | 14 (56%) | 11 (69%) |
Mother well-visit | 14 (34%) | 11 (44%) | 3 (19%) |
Baby symptoms/ sickness | 2 (5%) | 2 (8%) | 0 (0%) |
Mother symptoms/ sickness | 1 (2%) | 1 (4%) | 0 (0%) |
Observed visit characteristics | N = 45 | N = 26 | N = 19 |
Duration of Individual PPC counseling (median time in minutes) | 9.5 | 20 | 2.0 |
Counselling type | |||
Group | 12 (30%) | 5 (21%) | 7 (44%) |
Individual | 14 (35%) | 14 (54%) | 1 (6%) |
Both | 14 (35%) | 6 (25%) | 8 (50%) |
PPC visit number | |||
At discharge post delivery | 9 (22%) | 7 (27%) | 3 (16%) |
First follow up visit after delivery (within 7 days) | 20 (49%) | 14 (54%) | 7 (42%) |
Second visit (within 28 days) | 9 (22%) | 4 (15%) | 5 (32%) |
Third visit (within 42 days) | 12 (29%) | 1 (4%) | 2 (11%) |
PPC Visit recipient | |||
Child | 1 (2%) | 1 (4%) | 0 (0%) |
Mother | 13 (31%) | 1 (4%) | 11 (68%) |
Mother and child | 27 (67%) | 23 (92%) | 5 (32%) |
Provider used job aides | 12 (29%) | 1 (4%) | 10 (63%) |
Provider told client return visit date | |||
Sets a date for the next visit with the client | 41 (100%) | 25 (100%) | 16 (100%) |
Encourages her to return to the next planned visit | 40 (98%) | 24 (96%) | 16 (100%) |
PPC provider was the same as that who attended you during a previous visit to this health facility | 11 (26%) | 6 (23%) | 5 (29%) |
“If I come here and I don’t get any service for myself, I won’t care. But if my child won’t be given immunization or nothing is done to her, I will question.” (28 years old, 15 days since delivery, PPC2)
“Some of them [mothers], they come for further mother health examination, but honestly speaking, most of them they don’t know if a mother should also be involved.” (28 years old, 15 days since delivery, PPC2)
“Other women do not come because they do not prioritize. They would rather do their chores at home than come for a clinic visit. She sees that her work is more important than the clinic visit.” (29 years old, 14 days since delivery, PPC2)
Processes
Domain | Total (n = 45) | Program (n = 26) | Comparison (n = 19) |
---|---|---|---|
Total Composite Score | 0.44 (0.17, 0.65)* | 0.46 (0.08, 0.72)* | 0.27 (−0.21, 0.64) |
Maternal Health | 0.56 (0.31, 0.73)* | 0.52(0.15, 0.76)* | 0.48 (0.04, 0.77)* |
Infant & child health | 0.41 (0.13, 0.63)* | 0.22(− 0.19, 0.57) | 0.46(0.01, 0.76)* |
HIV | 0.27(− 0.03, 0.53) | 0.1(− 0.31, 0.47) | 0.37 (− 0.1, 0.71) |
Family Planning | 0.02 (− 0.28, 0.32) | 0.51 (0.14, 0.75)* | − 0.34 (− 0.69, 0.14) |
PPC users also reported that when women who delivered at home do reach services, they were often treated harshly by providers and/or asked to pay out of pocket costs for PPC services.“Many don’t come for ANC visit and they deliver at home, so they don’t get a chance to know the importance of PPC visits.” (23 years old, 21 days since delivery, PPC3)
“Sometimes, those who have delivered at home, they are mistreated…when they come for PPC and they have to pay some amount for them to start PPC visits. For example, I paid 3000 shillings so that I could get a card to start PPC services for myself and my child.” (23 years old, 21 days since delivery, PPC3)
“…saying the truth when they come here… We blame them, why did she decide to give birth at home.” (Enrolled nurse, 3 years experience, no PPC training)