Postpartum Care Survey Results from Sub-Saharan Africa

This postpartum care survey from the ACCESS Program on family planning (FP), ACCESS-FP, was created to identify, document, and share information on the status of postpartum care (PPC) services implemented by United States Agency for International Development (USAID) cooperating agencies. The report on results from the sub-Saharan African region agencies describes the purpose and scope of the survey, and presents results that are intended to be helpful for programme managers, policymakers, and health care providers when implementing postpartum care activities. It is based on a model developed in 2005 by the Extending Service Delivery Project and CATALYST for the Asia and Near East region.

From the Executive Summary:
"A total of 37 projects in sub-Saharan Africa responded to the survey; most were working in FP, HIV/AIDS, child survival/child health and maternal and newborn health. Training, service delivery, behavior change communication and community approaches were the main intervention areas of the projects surveyed. Since most of the projects work with women of reproductive age and children under five years, there are opportunities to integrate postpartum family planning (PPFP) with routine immunization, well-child and sick-child visits. Opportunities to include ...PPFP in trainings also exist in a number of the projects. Survey results indicated that there are a number of opportunities to integrate postpartum family planning (PPFP) with many programs."


Recommendations include:
1. Utilise community-based volunteers in PPFP interventions and refer for clinical methods;
2. Emphasise LAM [Lactational Amenorrhea Method] as a transition method;
3. Advocate for policies that effectively promote PPFP;
4. Ensure availability of a range of FP methods for postpartum women to transition;
5. Develop PPC/postnatal care (PNC) packages to include PPFP to guide policymakers and service providers.

The document gives statistics on profiles of the 37 responding organisations, particularly their intervention focus, the population on whom they focus, and the timing of postpartum services of 17 of the providers who responded. More specifically, the survey describes the 21 PPFP counselling services (some focusing on mother and infant care, but including PPFP). "For the content of PPFP counseling, most projects emphasized all family planning methods appropriate to fertility intentions and the LAM." While all 21 projects expressed their support for the LAM, the use of other FP content varied. PPFP counselling content includes: trainings in general; behaviour change communication (BCC)/information and education communication (IEC); promotion of exclusive breastfeeding; and counselling. In addition to the PPFP counselling activities mentioned, most projects (18 out of 21) are engaged in facility-based PPFP services up to 12 months postpartum. (Data on type and availability of contraceptives provided by these services are given.)

Maternal and newborn care services are described as follows:

1. Maternal care includes - among other nutritional, hygiene, and HIV-related therapies - counselling on maternal danger signs, breastfeeding, malaria prevention, awareness raising on female genital mutilation, and safe birth planning, as well as adolescent friendly services.
2. Newborn care services includes - along with nutrition, infection, resuscitation, prevention of mother to child HIV transmission care (PMTCT) therapies, and monitoring - counselling on danger signs related to newborns, early and exclusive breastfeeding, thermal protection, cord care, harmful traditional practices, "Kangaroo Mother Care" (Kangaroo care is a way of holding a preterm or full term infant so that there is skin-to-skin contact between the infant and the person holding it), and immunisation.

Best practices shared by 12 projects include:

• working closely with volunteers (referrals or health education) resulted in improved post abortion care (PAC) or PNC coverage;
• train matrons for care and support according to FP standards;
• community mobilisation;
• decentralisation of PAC;
• in-depth supervision;
• outreach activities;
• quality assurance; and
• use of community midwives.

Three projects also shared their lessons learned and recommended that programmes avoid:

1. Focusing on supply only and forgetting the demand and advocacy strategies; and
2. Lacking emphasis on PNC during training and follow-up support supervision.

The document includes a chart listing in one column the barriers faced by implementers of projects at the policy, service delivery, community, and household level. The chart also lists a column of recommendations for working towards solutions for each barrier. Communication-related barriers with corresponding recommendations are listed below:

• Barrrier: Lack of community buy-in - Recommendation: Adapt/improve postpartum modules, tools, and adapted behaviour change communication (BCC) materials;
• Lack of well-developed tools and modules - Organise training of health workers at clinical and community level with a particular focus on pre-service training;
• Lack of Ministry of Health (MOH) buy-in, especially for full PPFP services, and/or lack of an appropriate policy - Advocacy, particularly for policy development;
• Shortage of skilled staff or staff turnover - Strengthen providers’ capacity, improve service quality, and ensure sustainability through provider trainings and skill/information updates;
• Low rate of postpartum visits and late antenatal care (ANC) attendance - Organise outreach activities for postpartum care, reach the community by an advanced or mobile strategy;
• Traditional practices or cultural beliefs and lack of knowledge of importance of antenatal and postpartum care - Community health education and promotion and behaviour change communication for increased communication and awareness;
• Lack of availability of a trained cadre of community agents - Training for community-level cadres to provide quality PPC;
• Low male/partner involvement - Behaviour change communication; and
• Stigma of HIV-positive mothers negatively affects infant feeding practices - Programmes to address stigma against people living with HIV/AIDS (PLWHA) - especially regarding HIV-positive mothers who choose replacement feeding - and community sensitisation.