Postpartum care

Postpartum care (PNC) is a very important part of maternal care, because some truly life-threatening complications may occur during the postpartum period, even in women with normal pregnancy and childbirth. Postpartum care is also extremely important for finding and managing neonate problems. Postnatal care in Nepal is traditionally uncommon. Most mothers and their newborn babies will contact health services, such as medical care, for the first time when their babies are vaccinated six weeks after birth. The period after childbirth is the cause of widespread death of females and their infants. In fact, postpartum hemorrhage (PPH) is the most common reason for maternal mortality in Nepal; although under-five mortality has declined between 2006 and 2011, neonatal mortality remained a constant.

The Ministry of Health and Population recommends at least three post-natal visits under special circumstances: within 24 hours of birth—on the third day of birth, and on the seventh day of birth. Generally, Nepali women and their babies receive some form of post-natal care in the first seven days after childbirth; this kind of care is usually provided by nurses or midwives. The most powerful predictor of receiving postpartum examination is that it is supplemented in medical institutions. Different factors that make women more likely to receive postpartum care include living in an urban environment, in the terai, rather than in hilly or mountainous regions, with its better socio-economic status and better training facilities

Many factors have proven to influence the acceptance and utilization of primary care in Nepal. The boundaries of care include lack of attention to post natal care needs, increased distance from health facilities, lack of delivery or good enough roads, lack of health facilities in the community, financial constraints, and lack of empowerment and decision-making capacity of women, especially in terms of mobility or expenditure. Mothers or mother figures often have the right to decide whether women receive prenatal care, which in turn affects the use of postpartum care; women receiving antenatal care (ANC) are more likely to return to postpartum care. Exploring the impact of male participation helped discover that women assigned to prenatal education with their husbands were more likely to participate in post-natal visits several weeks after childbirth, rather than untrained women or women who participated in prenatal training alone. The type of delivery care that the delivery care provider gives also plays a key role; women who give birth when the midwife is the primary provider are more likely to receive postpartum care in the medical center. In addition, cultural beliefs and some socio-cultural practices, such as maternal segregation two to four weeks after childbirth, pose additional restrictions on access to care.

Over the last few years, Nepal has taken several initiatives focusing on increasing access to quality postpartum care. Many projects are supported by the Government of Nepal, while others are operated by private or multilateral organizations. Some flagship programs and their impact on maternal and newborn health outcomes are:

1. Birth Preparedness Package (BPP)
In order to improve the quality of maternal health care and reduce maternal mortality, the birth preparedness package (BPP) encourages women and their families to make plans for pregnancy, childbirth, and postpartum, so that they can effectively respond to emergencies. The plan provides families with information relating to what should be done at each stage of normal pregnancy and childbirth, helps identify signs of danger, and encourages families to save money to pay for normal childbirth and the normal possible complications along with it. BPP relies on the key information and behavior change of community health volunteers to bring in attention to the “three delays”: delay in identifying the problem, delay in seeking care, and delay in receiving care at the facility.
The government’s political will towards maternal health is reflected in Nepal’s success in reducing maternal mortality, the promotion of post natal care, and the focus on community care. Demand and supply side interventions have played an important role in improving maternal and neonate health nationwide. Maternal health is highlighted in Nepal’s national health planning, so a lot of attention has been paid to programs specifically targeting this area. Community-based programs encourage people to become familiar with receiving and participating in care and to promote care seeking behavior. Many post-natal programs have been expanded to the national level; comprehensive, high-quality care guidelines, community support, and a sufficient number of appropriately trained personnel have proved critical to success.

2. Community-based Neonate Care Package (CB-NCP)
The Ministry of Health launched the National Newborn Health Strategy in 2004 to bring into light the problem of high neonatal mortality. In 2007, an assessment of newborn health in Nepal found that although there were individual health promotion activities, there was a lack of a comprehensive and integrated program. This led to the development of the Community-based Neonate Care Program (CB-NCP) in the same year, which was started in 2010 in 10 districts through a partnership between the Government of Nepal, Save the Children, Care, Plan, and UNICEF. The plan relies on mobilizing existing female community health volunteers (FCHVs) to expand newborn health services at the community level. This approach has proven successful in child health interventions, such as community-based integrated management of childhood illnesses (CB-IMCI), vitamin a supplementation (VAS), and expanded immunization programs. CB-NCP aims to change health-related behaviors in the community, promote institutional delivery or clean home delivery, and provide postpartum care at home on the first, third, and seventh days after birth. It also teaches mothers the knowledge of Kangaroo Mother Care for low birth weight infants, and trains FCHVs in the management and prevention of infection and other necessary neonate care. FCHVs are the catalysts in linking communities with health facilities, and they mention more complex cases that cannot be directly managed within the community. Especially at home, early home visits and basic interventions provided by FCHVs shortly after birth are essential to prevent serious incidence rate and mortality among mothers and newborns.
The CB-NCP pilot was designed to determine the effectiveness and scalability of the program to guide further expansion. The assessment includes monitoring data, comparison of baseline and endpoint indicators, and qualitative data from community members, FCHVs, and stakeholders. Overall, the midterm review has shown encouraging results. However, although the coverage and utilization of neonatal care services have improved, the quality of data and service provision has been questioned. Data from Bardiya, one of the pilot areas, showed that the proportion of women who received postpartum examination within two days after delivery increased from 65% at baseline to 94% after 18 months. In all pilot areas, the proportion of women who were informed of pregnancy complications during antenatal care increased from 75% to 96% from baseline to the end point. Women are also more likely to have a family plan (70% versus 97%). Although the assessment of sustainability is ongoing, the Ministry of Health has been expanding CB-NCP since 2011, and it is expected that the plan will be expanded nationwide by 2015.

3. Nepal Family Health Program II (2007-2012)
Nepal Family Health Plan II (NFHPII) is a five-year bilateral project funded by the United States Agency for International Development (USAID). The project was launched by JSI in 2007 under the supervision of the Ministry of Health and Population to increase access to maternal and child health services in rural areas. The program focuses on improving commodity supply chains and increasing access to family planning and basic health services, thus improving maternal and child health outcomes and enhancing provider skills. Through various collaborations, NFHPII increased the proportion of women receiving postpartum care in the target area from 41% in 2008 to 55% in 2011.

NFHPII recognizes that Nepal is in great need of post-partum family planning (PPFP). Most of the unmet needs are due to insufficient understanding of PPFP needs by Nepali care providers. The poor coordination of family planning services, ANC providers, obstetric wards and postpartum care providers also led to the unmet needs of PPFP.
NFHPII worked with the Department of Family Health of the Ministry of Health and Population to prepare training materials for the three-day PPFP seminar. The workshop aims to teach providers to promote healthy pregnancy time and interval, increase their understanding of contraceptive methods for post natal and post abortion women, and strive to better integrate the services of different types of providers in different facilities.
The training workshops were piloted in 10 regions in 2008 and 2009, benefiting 240 providers. Nurses and medical staff participated in the training course and reported their understanding of postpartum family planning needs after the seminar. Additionally, the statistics of the pilot hospitals show that after the training, the PPFP provided to new mothers has increased to 44%, while before the training, it was only 4%. The use of family planning services has also seen a similar increase, with post natal women increasing from 20% to 31%, and women receiving post abortion care from 61% to 74%.

Community health workers and non occupational health workers are advised to use misoprostol (600 μG orally) to prevent postpartum hemorrhage when settings where skilled birth attendants are not present and oxytocin is not available. Like CB-NCP later, NFHPII relies on female community health volunteers (FCHVs), who are already trusted members of the community to maximize the scope and acceptability of misoprostol. FCHVs received training to disseminate accurate, high-quality information on misoprostol in women’s groups and home visits. Misoprostol was promoted as “Matri Surakchya Chakki” (Mothers’ safety pills), and directly distributed to women in the eighth month of pregnancy. The NFHPII FCHV training lasted seven days, three of which focused on misoprostol. The final data showed that 73% of women who had recently given birth received misoprostol, 74% of whom used it. This led to a significant increase in the uterine nutrition coverage rate of women in vaginal delivery from 11% to 74%, with the most significant change occurring in home delivery. Importantly, the observed maternal mortality rate (72 per 100,000) was significantly lower than the expected mortality rate (281 per 100,000) and also lower than that of non-users (292 per 100,000). After the success of this intervention, the Government of Nepal expanded the community distribution of misoprostol, targeting remote areas with low institutional delivery rates, with a view to scaling up nationwide.

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