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Postpartum/Newborn Care in Developing Countries: Too Little, Too Late and Unequal

Postpartum/Newborn Care in Developing Countries: Too Little, Too Late and Unequal. American Public Health Association (APHA) 2007 Conference Poster Presentation Tuesday November 6, 2007. Alfredo Fort, MD, PhD (DHS/PATH) Monica Kothari, MS, MPH (DHS/PATH)

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Postpartum/Newborn Care in Developing Countries: Too Little, Too Late and Unequal

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  1. Postpartum/Newborn Care in Developing Countries: Too Little, Too Late and Unequal American Public Health Association (APHA) 2007 Conference Poster Presentation Tuesday November 6, 2007

  2. Alfredo Fort, MD, PhD (DHS/PATH) Monica Kothari, MS, MPH (DHS/PATH) Noureddine Abderrahim, MSc (DHS/Macro International)

  3. Facts • Maternal and Neonatal mortality still high (over 500,000 maternal and 4 million newborn deaths every year) • 99% of deaths are in developing world • Causes and timing of deaths better understood: Maternal • 1/4 of maternal deaths occur during labor/delivery/<24 hrs. PP and 60% by the end of 1st week postpartum (worse for neonatal health) • Single most important killer: Postpartum Hemorrhage (PPH): around 1/4 maternal deaths; majority of deaths < 4 hours! (WHO recommendation of PPC within 6-12 hours postpartum: too late!) Neonatal • Three-quarters of neonatal deaths occur during first week • One million deaths within 24 hours • Most important killers: Infections (36%), Preterm birth/low birth weight (28%) and Birth Asphyxia/complications (23%)

  4. Achievements Coverage of Maternal Health Services

  5. Concerns • We know much more about antenatal care (ANC) and delivery, but little about postpartum/postnatal care (PPC/PNC), especially in the developing world PPC/PNC • How much? - Extent • When? – Timing • By Whom? - Provider

  6. MATERNAL MORTALITY ANC DELIVERY PPC/PNC Occurrence First ANC visit No. of ANC visits Provider of care Place of care Provider of care Place of care Timing of care Provider of care Correlates Woman’s Age, Education, R/U residence, Wealth, Parity; Head of Household; Woman’s Employment; Media Exposure; Health Care Decision Making DEPENDENT VARIABLES INDEPENDENT VARIABLES ANC = Antenatal Care; PPC = Postpartum Care; R/U = Rural/Urban Conceptual Framework of the Determinants of PPC

  7. Methodology • Study utilizes data from 30 DHS surveys conducted between 1999 and 2004 • PPC/PNC: from “after delivery” to 41 days PP • This is a women-based approach (i.e. “most recent birth in last five years”) as opposed to child-based approach – appropriate for pregnancy and delivery-related indicators • Includes institutional births (IB) and non-institutional births (NIB) • Key assumption: all IB received PPC/PNC (DHS has not asked PPC/PNC questions for IB until recent surveys) • Will use PPC as terminology throughout

  8. Levels of Postpartum Care

  9. Half of countries: >40% no PPC

  10. * 7.3 2.1 * Only 8% of NIB get PPC < 24 hrs. PP

  11. Place of Postpartum Care (IB + NIB) Outreach PPC?

  12. Provider of PPC (NIB) Sizable “Others”

  13. Determinants of Postpartum Care(Institutional + Non-institutional Births)

  14. PPC by Age Indonesia 2003/04 Peru 2000 Burkina Faso 2003 Egypt 2000 Haiti 2000 Rwanda 2001 Nepal 2001 Ethiopia 2000

  15. PPC by Birth Order Indonesia 2003/04 Burkina Faso 2003 Peru 2000 Egypt 2000 Haiti 2000 Nepal 2001 Rwanda 2001 Ethiopia 2000

  16. PPC by Area of Residence SubSA: Sub-Saharan Africa, NA: North Africa, WA: West Africa, E: Europe, CA: Central Asia SSA: South/South East Asia, LAC: Latin America & Caribbean

  17. PPC by Wealth Index Indonesia 2003/04 Peru 2000 Burkina Faso 2003 Egypt 2000 Haiti 2000 Rwanda 2001 Nepal 2001 Ethiopia 2000

  18. PPC by Education

  19. PPC by Number of Antenatal Care Visits

  20. PPC by Media Exposure (Watching TV) For Nepal Information is not available

  21. PPC by Health Care Decision Making

  22. Multivariate Analysis

  23. Variables Included in Multivariate Model

  24. Results: Logistic Regression *p<0.05; **p<0.01; ***p<0.001; NI: did not make into the model

  25. Results: Logistic Regression…contd. *p<0.05; **p<0.01; ***p<0.001; NI: did not make into the model; ---: no information

  26. Turkmenistan (4.3, 81.4) Indonesia (59.0, 83.6) Cambodia (89.2, 48.9) Colombia (12.4, 16.9) Rwanda (74.3, 4.3) Malawi (43.8, 7.3)

  27. Conclusions

  28. Births and PPC • Non-institutional births correlate weakly –and negatively- with PPC (see Scatterplot) • “Exceptions” (there are several outliers): • Positive: Turkmenistan, Indonesia and Cambodia = higher PPC than expected • Negative: Colombia, Malawi and Rwanda = lower PPC than expected

  29. Timing of PPC • Non-institutional births: Left to their own device. • Three-quarters do not receive PPC • Of those who do, only 8 % receive PPC < 24 hours. • Average (median) PPC (NIB) = 3 days post-partum! • All births (grouping IB + NIB): Average (mean) PPC = 2 days post-partum Too little, too late!

  30. Where is PPC provided and by Whom? Place • Majority of women in Cambodia, Indonesia and Nepal receive first PPC at home • In a few African countries: ¼ - ⅓ PPC = at home Attendant • In Rwanda, Ghana, Mali, Nigeria, Cambodia & Nepal most PPC for NIB = by TBAs • Majority of providers are health personnel for Indonesia • Haiti (NIB): 40% PPC by TBA + 25% by “Others”

  31. Who receives more PPC (after controlling for other variables)? • The wealthier, more educated, with a first child, who had antenatal care, lives in urban areas and reads news/watches TV • Does not matter: age, employment, who is head of household, whether woman or others decide for her health • Exceptions: No media exposure effect in Egypt; No urban residence effect in Haiti and Nepal • Latest: When broken down by IB and NIB, the patterns differ (usually oppose)

  32. Limitations • Assumption about Institutional Births and PPC/PNC: overestimate PPC/PNC? • Assumption about the timing of PPC/PNC for IB (no data on “hours”): over/underestimate of early PPC/PNC? • PPC/PNC is only “contact”: No content; cannot place value on the quality of PPC/PNC • There might be differential care: e.g. more PPC than PNC or viceversa • Recall bias: less precision for “older” births

  33. Recommendations • For PPC/PNC to occur within 2-6 hours after delivery: likely that skilled attendance will be needed at delivery (or prompt/effective community-skilled provider links). • Indonesia model: seems to work to close gap between home deliveries and PPC/PNC (for countries with large rural areas) • train skilled attendants and deploy them to rural areas • During ANC and through community health education campaigns: importance of skilled attendance/institutional delivery and birth plan • Invest in upgrading EmOC centers • Need to disaggregate PPC from PNC (new surveys) and undertake qualitative research to understand perceptions of care

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