Community-Based Postpartum Care Services in MotherNewBorNet Member Programs

This 56-page report compiles results from a survey conducted to identify, document, and share information on the status of community-based (CB) postpartum care (PPC) and postpartum family planning (PPFP) services implemented by MotherNewBorNet (MNBN) member organisations in the Asia Near East (ANE) region. MNBN is a network established in 2005 to improve maternal and neonatal health at the community level. At the time of this study, it was being hosted by the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B): Center for Health and Population Research, with financial assistance from the United States Agency for International Development (USAID).

In the summer of 2007, USAID's Extending Service Delivery (ESD) Project sent a structured questionnaire electronically to 50 individuals representing member projects and organisations within MNBN, of which 28 responded. The questionnaire covered the following topics: project background, provision of PPC services, newborn care, best and promising practices, challenges faced, monitoring and evaluation (M&E), recommendations for improvement, and lessons learned.

Selected findings include:

• In areas where participating projects are working, 70% of births took place in the home. Only 10% were reported to be assisted by skilled birth attendants, and 37% were assisted by traditional birth attendants (TBAs).
• The majority of projects are actively mobilising different categories of community-based health workers (CHWs) to identify women in the community for PPC services.
• According to ESD, 3 common models of CB PPC exist in the field: 1) home visits by professional health care providers; 2) home visits by CHWs with little or no referral provided (primarily used for newborn care home visit programmes rather than maternal health programmes); and 3) home visits by CHWs with referral or health facility support. When asked about the model that best described their PPC services, the majority (18/19) cited model 3. The ratio of provider (CHW/volunteer with an education level of 10th grade) to population reported by respondents in this model ranged from 1:60 to 1:5000.
• Overall, 68% of respondents reported providing CB PPC and 84% reported PPC visits within the first 3 days following delivery. Nevertheless, there appears to be a range of other postpartum contacts, and "[i]t appears there is yet no consensus or standardization on the most effective timing or frequency of postpartum visits for optimal benefits to mother and newborn."
• Regarding newborn care, early and exclusive breast-feeding was the most utilised promising and best practice, reported by 89% of respondents. Seventy-five percent of respondents reported counseling on postpartum contraception, with counseling on contraceptive pills occurring most frequently (57%). (For further details and statistics on other promising and best practices in PPC explored in the survey, see pages 14-16).
  
• The majority of respondents reported that their service providers have been trained in delivery of PPC. Among those whose providers received such training, the majority reported that PPFP was included as part of that training. According to ESD, "[i]t is important that all service providers are trained in provision of postpartum care, i.e., all elements of PPC similar to training service providers in essential components of focused [antenatal care, or] ANC and newborn care...PPFP counseling should be an essential element of PPC training."
• As reported by survey participants, effective practices include: presence of referral mechanisms, home visits, community care starting from ANC, establishing community support systems, and focusing on activities valued by the family.
• In terms of challenges faced, at the policy level, 50% of respondents cited lack of funds and lack of priority given to PPC programmes as key barriers to implementation. At the service delivery level, 61% of respondents cited lack of training in PPC as the primary barrier. Finally, 68% of respondents reported that PPC was not considered a priority for the family, with 64% citing community norms as barriers.
• The top 3 reasons for not providing FP counseling were: FP is not considered a priority by the woman/family; focus is on the newborn in the postpartum period; and CHWs have not been trained in FP counseling.
• The majority (75% or 16/21) reported that their projects monitor their PPC activities. In sum, respondents cited nearly 50 different indicators for monitoring PPC activities, among which only 2 were related to family planning. (These indicators are listed on pages 19-20).
  
• Almost all (96% or 27/28) respondents reported that the "ideal window of opportunity" for PPFP counseling is both before and after delivery. Eighty-nine percent of respondents reported that the ANC clinic was the ideal place before delivery, and 85% (24/28) reported that the home was the ideal place post-delivery.

In essence, home-based PPC is described as having "good impact on the mother and newborn," as being "essential," and as being an "effective means for increasing the coverage". ESD found that both TBAs and CHWs play important roles in delivery of home-based PPC. For example, TBAs are reported as being "effective if there is good supervision." Many respondents described them as playing an important role during postnatal period. While it is "convenient to have TBAs provide PPC", respondents stressed that "a good linkage with a health facility is important.""

Based on survey findings, select prioritised strategic recommendations are as follows:

• Increase service providers' knowledge and skills related to essential PPC services that must be provided at a minimum, including timing and frequency of postpartum visits and PPFP. To that end, a consensus needs to be reached among international organisations and postpartum advocates for a prototype "essential integrated PPC minimum package" (similar to the essential newborn care package and focused ANC package).
• Improve community support for PPC by strengthening social mobilisation and community involvement activities to increase community/families' awareness, demand, and use of PPC - particularly in areas where PPC is "not considered a priority by the family," and PPC is "not considered a community norm."
• Improve the skills of CHWs and TBAs in provision of select integrated PPC, including early PPC home visits and PPFP information. Integration of PPFP into focused ANC, prevention of mother-to-child transmission of HIV (PMTCT) services, and other maternal and child health (MCH) consultations such as immunisations and well-baby clinics is also recommended.
• Continue advocacy for PPC among policymakers to update national guidelines and protocols on integrated PPC to include essential components of integrated PPC, such as who will provide PPC, where and when, and what skills are needed. Collaborate with appropriate professional bodies and training institutions to ensure that PPFP is included in all appropriate communication and counseling protocols and guidelines.
• Identify a basic list of minimum standard indicators which can be adopted/adapted by national Ministries of Health for use by their field workers. "It is also important to consider not overburdening health workers or health systems with too many indicators, but rather help to streamline and be more strategic in identifying only the major indicators that best reflect the outcome we are striving for."
• Address identified weaker areas through: 1) South-to-South exchanges within the same country or across the region; 2) disseminating findings and programmatic implications from completed operational research studies; and 3) further research into underlying challenges, barriers, and issues to more efficiently address them.

"It is hoped that many of the survey's lessons learned, recommendations and successful practices can be widely used, applied or adapted to improve CB PPC and PP FP not only in the Asia and Near East region, but also as in other geographical regions facing similar challenges."