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

American Public Health Association (APHA)

2007 Conference Poster PresentationTuesday November 6, 2007

Alfredo Fort, MD, PhD (DHS/PATH)

Monica Kothari, MS, MPH (DHS/PATH)

Noureddine Abderrahim, MSc (DHS/Macro International)

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%)

Achievements

97

65

99

53

90

30

Antenatal care Skilledattendant at

delivery

PostpartumCare

DevelopedcountriesDevelopingcountries

Coverage of Maternal Health Services

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

Conceptual Framework of the Determinants of PPC

Place of careProvider of care

OccurrenceFirst ANC visitNo. of ANC visitsProvider of care

ANC DELIVERY PPC/PNCMATERNALMORTALITY

Place of careTiming of careProvider of care

CorrelatesWoman’s Age, Education, R/U residence, Wealth, Parity; Head of Household; Woman’s Employment; Media Exposure; Health Care Decision Making

INDEPENDENT VARIABLES

DEPENDENTVARIABLES

ANC = Antenatal Care; PPC = Postpartum Care; R/U = Rural/Urban

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

Levels of Postpartum Care

Postpartum Care (IB and NIB)

0102030405060708090

100

Perc

ent B

irths

Institutional Births NIB with PPC NIB without PPC

Half of countries: >40% no PPC

Mean and Median Timing of PPC (days)

0.01.4 1.7 1.8 1.1 1.4 1.2 1.8

0.0

1.9 2.4 2.8 2.6 2.9 2.9

6.9

3.9

7.0

3.4

1.4 1.4

3.3

8.2 8.710.2

9.1

14.114.714.8

3.2

0

5

10

15

20

25

Day

s PP

C

Mean time to PPC (NIB) Median time to PPC (NIB) Mean time to PPC (All Births)

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

7.3

2.1

*

Place of Postpartum Care (IB + NIB)

0.00

0.20

0.40

0.60

0.80

1.00

Cambo

dia 20

00

Nepal

2001

Indon

esia

2002

-2003

Haiti 2

000

Nigeria 2

003

Ethiopia

2000

Ghana

2003

Mali 20

01

Burkina

Faso 2

003

Kenya

2003

Zambia

2001

Rwanda

2001

Ugand

a 2000

Armen

ia 20

00

Eritrea

2002

Egypt

2000

Turkmen

istan 2

000

Peru 20

00

Malawi 2

000

Namibi

a 200

0

Benin

2001

Zimba

bwe 1

999

Domini

can R

ep 20

02

Nicarag

ua 20

01

Jorda

n 200

2

Colombia

2000

Perc

ent

Health Facility Home or other placesOutreach PPC?

0

10

20

30

40

50

60

70

80

90

100

Mali 2

001

Rwanda

200

1Nep

al 2

001

Cambo

dia 20

00Gha

na 2

003

Haiti 2

000

Madag

asca

r 200

3Nig

eria

200

3

Camer

oon

2004

Bang

lades

h 20

04Mal

awi 2

000

Ugand

a 20

00Za

mbi

a 20

01Ke

nya

2003

Indon

esia

2002

-200

3

Burk

ina F

aso

2003

Ethi

opia

200

0Be

nin

2001

Namib

ia 20

00Eg

ypt 2

000

Eritr

ea 2

002

Domin

ican R

ep 2

002

Arm

enia

200

0

Zimba

bwe

1999

Turk

men

istan

200

0Pe

ru 2

000

Mozam

biqu

e 20

03

Nicara

gua

2001

Jord

an 2

002

Colom

bia 2

000

Other*Any TBAHealth Professionals

Provider of PPC (NIB)Sizable “Others”

Determinants of Postpartum Care

(Institutional + Non-institutional Births)

PPC by Age

0

20

40

60

80

100

<20 20-24 25-29 30-34 35-49

Age in years

Perc

ent

Indonesia 2003/04

Peru 2000

Ethiopia 2000

Burkina Faso 2003Egypt 2000

Haiti 2000

Rwanda 2001Nepal 2001

PPC by Birth Order

0

20

40

60

80

100

1.0 2 to 4 5+Birth Order

Perc

ent

Indonesia 2003/04

Peru 2000

Ethiopia 2000

Burkina Faso 2003

Egypt 2000Haiti 2000

Rwanda 2001Nepal 2001

PPC by Area of Residence

0

20

40

60

80

100

Perc

ent

Rural Urban

SubSA NA/WA/E/CA SSA LACSubSA: Sub-Saharan Africa, NA: North Africa, WA: West Africa, E: Europe, CA: Central AsiaSSA: South/South East Asia, LAC: Latin America & Caribbean

PPC by Wealth Index

0

20

40

60

80

100

120

Lowest Second Middle Fourth Highest

Wealth Quintiles

Perc

ent

Rwanda 2001Nepal 2001

Haiti 2000

Indonesia 2003/04Peru 2000Burkina Faso 2003Egypt 2000

Ethiopia 2000

PPC by Education

0

20

40

60

80

100

Indonesia2002/03

BurkinaFaso 2003

Egypt2000

Ethiopia2000

Haiti 2000 Nepal2001

Peru 2000 Rwanda2001

Perc

ent

NoEducation

Primary Secondaryor higher

PPC by Number of Antenatal Care Visits

0

20

40

60

80

100

Indonesia2002-2003

BurkinaFaso 2003

Egypt 2000 Ethiopia2000

Haiti 2000 Nepal 2001 Peru 2000 Rwanda2001

Perc

ent

None 1 - 3 4 or more

PPC by Media Exposure (Watching TV)

0

20

40

60

80

100

Indonesia2002-2003

BurkinaFaso2003

Egypt2000

Ethiopia2000

Haiti 2000 Peru2000

Rw anda2001

Per

cent

Watches TV - No Watches TV - Yes

For Nepal Information is not available

0

20

40

60

80

100

Indonesia2002-2003

BurkinaFaso2003

Egypt2000

Haiti 2000 Nepal2001

Peru 2000 Rwanda2001

Perc

ent

Self Jointly Others

PPC by Health Care Decision Making

Multivariate Analysis

Variables Included in Multivariate Model

DIMENSIONNo. VARIABLE VALUES

Socio-demographic 1) Birth order (representing parity):

1, 2-4, 5+

2) Wealth (quintiles) Lowest, Second, Middle, Fourth, Highest

3) Residence Urban, Rural

4) Woman’s Education None, Primary, Secondary+

5) Woman’s Employment Not working, Working

Exposure

Previous health exposure/contact 6) No. ANC visits 0 (no ANC), 1-3, 4+, DK/missing

Media exposure 7) Newspapers Yes, No

8) Television Yes, No

Status - Health Care Decision-making (HCDM)

9) Woman’s HCDM Self, Jointly, Others

Results: Logistic Regression

Country/Background Characteristics

Burkina Faso2003

Egypt2000

Ethiopia2000

Haiti2000

Nepal2001

Peru2000

Rwanda 2001

ResidenceUrbanRural

1.000.46***

1.000.65***

1.000.41***

NI NI 1.000.47***

1.000.39***

Woman’s EmploymentNoYes

NI 1.001.27**

NI 1.001.12*

1.000.35***

NI NI

Birth order12-45+

1.000.69***0.80*

1.000.53***0.51***

1.000.63***0.75**

1.000.67***0.51***

1.000.77**0.82

1.000.71***0.59***

1.000.37***0.33***

Woman’s EducationNonePrimarySecondary or higher

1.001.74***3.36*

1.001.21*1.38***

1.001.27*2.28***

1.000.891.99***

1.000.72**1.21

1.000.941.59***

1.001.44***3.99***

Wealth (quintiles)LowestSecondMiddleFourthHighest

1.001.33**1.67***2.16***4.31***

1.001.21*1.67***1.95***3.99***

1.000.910.921.332.15***

1.001.131.33*2.60***4.56***

1.001.61***2.29***1.65***3.12***

1.001.47***2.52***4.27***11.45***

1.000.910.931.122.21***

*p<0.05; **p<0.01; ***p<0.001; NI: did not make into the model

Results: Logistic Regression…contd.

Country/Background Characteristics

Burkina Faso2003

Egypt2000

Ethiopia2000

Haiti2000

Nepal2001

Peru2000

Rwanda 2001

Number of Antenatal Care VisitsNone1-34+DK/ELSE

1.009.37***15.29***8.53***

1.001.63***3.86***2.95***

1.002.38***4.83***4.13***

1.001.57***2.69***2.54**

1.002.52***4.99***7.24**

1.002.60***5.77***2.73**

1.003.77***8.37***1.68

Read NewspaperNoYes

1.003.36**

NI 1.001.34*

1.001.40***

------ 1.001.35***

1.001.21*

Watch TelevisionNoYes

1.002.13***

NI 1.001.91***

1.001.39***

------ 1.001.16*

1.001.67***

Woman’s HCDMSelfJointlyOthers

1.001.230.91

1.000.990.86**

--------- NI NI 1.000.900.66***

1.000.901.13

*p<0.05; **p<0.01; ***p<0.001; NI: did not make into the model; ---: no information

Linear Regression

0.00 25.00 50.00 75.00

NIB

20.00

40.00

60.00

80.00

PPC

NIB

PPCNIB = 48.55 + -0.36 * NIBR-Square = 0.21

Correlation between Non-Institutional Births and Post-partum CarePercentages

Turkmenistan (4.3, 81.4)

Indonesia (59.0, 83.6)

Cambodia (89.2, 48.9)

Colombia (12.4, 16.9)

Malawi (43.8, 7.3)

Rwanda (74.3, 4.3)

Conclusions

• 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

Births and PPC

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!

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 homeAttendant• 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”

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)

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

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