Postnatal care (PNC) is the care given to the mother and her newborn baby immediately after the birth and for the first six weeks of life (Figure 1.1). This period marks the establishment of a new phase of family life for women and their partners and the beginning of the lifelong health record for newborn babies (or neonates — a term often used by doctors, nurses and midwives).
Although for most women and babies, the postnatal period is uncomplicated, effective postnatal care (PNC) is also about recognising any deviation from expected recovery after birth, and evaluating and intervening appropriately in a timely fashion. It is of major concern that less than 6% of women in Ethiopia give birth in health facilities and not more than 10% receive any postnatal care within two days of delivery. Your role as a Health Extension Practitioner is therefore vitally important in improving this situation, identifying danger signs and reducing the adverse outcomes for mothers and newborns.
In Ethiopia, as in all countries, the postnatal period is often marked by specific cultural practices. Understanding the beliefs and cultural practices in your community is fundamental in ensuring appropriate postnatal care. In this first study session, you will learn why care in the postnatal period is so important, and about the need for community participation and involvement for optimum PNC. We briefly summarise some methods of community mobilisation, and how to establish partnerships with the key gatekeepers who can help you look after new mothers and their babies.
When you have studied this session, you should be able to:
1.1 Define and use correctly all of the key words printed in bold. (SAQ 1.1)
1.2 Explain the importance of postnatal care in terms of when most mothers and newborns die, and the main causes of these deaths. (SAQ 1.2)
1.3 Briefly describe the main physiological changes in the mother and newborn in the postnatal period. (SAQ 1.3)
1.4 Describe the main danger signs in the postnatal mother and newborn. (SAQ 1.3)
1.5 Explain the importance of community involvement in postnatal care and describe how you would establish partnerships with gatekeepers in the community. (SAQ 1.2)
The time when effective postnatal care can make the most difference to the health and life chances of mothers and newborns is in the early neonatal period, the time just after the delivery and through the first seven days of life. However, the whole of the neonatal period, from birth to the 28th day after the birth, is a time of increased risk. Deaths during the first 28 days of babies who were born alive is reported by all countries in the world as the neonatal mortality rate (the number of babies who die in the first 28 days) per 1,000 live births. Similarly, reports of maternal mortality include deaths of women from complications associated with postnatal problems, not just problems arising during the birth. Both these rates are important indicators of the effectiveness of postnatal care.
So the first reason why you need to focus more care and attention on the postnatal period is that this is a very critical time for the mother and her newborn baby. The national maternal mortality ratio (MMR) in Ethiopia is one of the highest in the world: at the last Demographic and Health Survey in 2005 (European calendar) 673 mothers died per 100,000 live births. Similarly, the early neonatal mortality rate was also very high, with 39 babies dying in the first week of life per 1,000 live births (EDHS, 2005). Ethiopia is one of five African countries that (together) account for half of all the newborn deaths in the whole of Africa.
This high risk period is also the time with the lowest coverage of maternal and child health care in Ethiopia. This is the second reason why you need to focus more attention on postnatal care.
If all newborns received high impact and cost-effective interventions during the postnatal period, it is estimated that neonatal mortality could be reduced by between 10-27%. In other words, high postnatal care coverage could save up to 60,000 newborn lives a year in Ethiopia, and help the country to meet the Millennium Development Goal of reducing under-five child mortality by two-thirds by the year 2015.
Ideally, postnatal care is best delivered in a health facility. However, due to many socio-economic and cultural reasons, such as the distance to travel and the cost of attending, most rural mothers give birth at home. Therefore, in the Ethiopian context, the most realistic way of providing optimum postnatal care for the foreseeable future is likely to be through home visits by a skilled health care worker such as you.
Mothers and their newborn babies are at highest risk of dying during the early neonatal period, especially in the first 24 hours following birth and over the first seven days after delivery (see Table 1.1). As you can see from the table, 45-50% of the mothers and newborns who die do so in the first 24 hours after birth, and 65-75% of the maternal and neonatal deaths occur within one week of birth. This is compelling evidence to provide optimum and integrated maternal and newborn care during the first few days after delivery.
|Deaths after delivery||First 24 hours (%)||First seven days (%)|
For some life-threatening maternal and newborn conditions, effective postnatal care is either given in the first few hours and days, or it will happen too late. The earlier these clinical conditions are detected, the more effectively they can be managed; the quicker they are referred for specialised treatment, the better the outcomes will be. Unfortunately, most of these interventions are highly time-dependant in order to be effective. You should keep this in mind while providing care to mothers and their babies in the first few days of postnatal life.
The main purpose of providing optimal postnatal care is to avert both maternal and neonatal death, as well as long-term complications. To be effective you therefore need to know the major causes of death in the postnatal period, so that you can provide quality and timely postnatal care at the domestic and Health Post level.
Knowing what mothers and newborns are dying from is important in order to identify the high impact interventions that address all the major causes of death during the postnatal period. Table 1.2 shows the percentage of maternal deaths from the major causes for women in Africa.
You learned about anaemia, hypertensive disorders and abortion in Study Sessions 18, 19 and 20 of the Antenatal Care Module. Obstructed labour and postpartum haemorrhage were taught in Study Sessions 9 and 11 of the Labour and Delivery Care Module.
|Causes of maternal death||Percentage (%)|
|Localised infection or disseminated infection (sepsis)||16|
|Hypertensive disorders of pregnancy (pre-eclampsia, eclampsia)||9|
|All other causes of death||30|
Table 1.3 shows the causes of newborn deaths in Ethiopia. You will learn about special care for preterm and low birth weight babies in Study Session 8 of this Module.
Infections, including diarrhoeal diseases and tetanus, are described in detail in the Communicable Diseases Module. Birth asphyxia and neonatal resuscitation were covered in Study Session 7 of the Labour and Delivery Care Module,
|Causes of newborn deaths||Percentage (%)|
∙ Other infections, including neonatal infection (sepsis)
|Prematurity and low birth weight||17|
|Congenital defects (deformities present at birth)||4|
|All other causes||7|
Why is it really important for you to understand the main factors causing mothers and babies to die in the postnatal period?
You probably thought of many reasons, but the most obvious one is the huge difference that the delivery of appropriate and prompt postnatal care could have on Ethiopia's neonatal mortality rate: a reduction of between 10-27%, or up to 60,000 newborn lives saved every year.
Think for a moment about the main causes of maternal and neonatal death. Which ones do you expect to see most in your role as a Health Extension Practitioner?
If you use the numbers in Tables 1.2 and 1.3, then you probably said postpartum haemorrhage for mothers and some form of infection for babies and also for mothers. You might also have picked out eclampsia (mothers) and neonatal asphyxia (babies).
The most critical period for complications in the postnatal mother arising from bleeding (post-partum haemorrhage) is in the first 4-6 hours after delivery, due to excessive blood loss from the site where the placenta was attached to the mother’s uterus, or from rupture of the uterus during labour and delivery. Haemorrhage can also threaten the baby’s life if it occurs before delivery and the baby is starved of oxygen and nutrients.
Both the mother and the baby are also at high risk of developing other complications if the physiological adjustments that take place in their bodies after the birth do not occur properly. This can result in loss of function or interruption of essential supplies of oxygen and nutrients needed to sustain life.
During labour and delivery, there is inevitably some loss of blood and other body fluids (for example, from vomiting and sweating), which is tolerable by the majority of women. Some degree of this is normal. Additionally, most women in labour remain for long hours without taking food or sufficient fluids, which can leave them dehydrated. Unless they are rehydrated quickly after the birth, physiological complications become more likely.
During pregnancy, activity in almost all the mother’s body systems changes, including the heart, lungs, blood volume and blood contents, reproductive system, breasts, immune system and hormones. In the postnatal period, all these dynamic body systems have to adjust from the pregnant state back to the pre-pregnant state, and there is a potential risk of complications as these adjustments occur. Common examples are breast infections and deep vein thrombosis (blood clots in the veins of the legs), which are described in Study Session 3 of this Module. The period in which these physiological adjustments take place in the postnatal mother is called the puerperium. You will learn all about it in Study Sessions 2 and 3.
Additionally, labour is a painful experience for most women, particularly for those giving birth for the first time. There is also tension and anxiety about the outcome of labour and delivery. Having a baby is a joy (Figure 1.1), but it can also be a source of worry. Women in the postnatal period are often coping with stressful conditions and thus they need sustained psychological support.
While in the uterus, the baby was well protected by the fetal membranes and the antibacterial action of the amniotic fluid in which it was bathed, and by maternal antibodies that cross the placenta and defend it against infections that the mother has already encountered. After birth, antibodies in the colostrum (first milk) and true breast milk, and natural barriers like the baby’s skin, give the newborn most of the protection from infection that it has when newly born. Its own immune system will take several months to develop adequately.
The newborn baby’s blood circulation system undergoes major adjustments when it takes its first breath outside the uterus. While the baby is in the uterus, very little blood goes to the lungs because the baby isn’t breathing air. The fetal lungs cannot perform the gas exchange (absorbing oxygen and releasing waste carbon dioxide), which occurs from the moment of birth onwards.
Where does fetal gas exchange occur during the baby’s life in the uterus?
Oxygen is absorbed into the fetal blood from the mother’s blood as they come close together in the placenta; carbon dioxide from the fetus passes into the mother’s blood and is expelled from her body in her breath.
You learned about gas exchange in the placenta in Study Session 6 of the Antenatal Care Module.
Immediately at birth, the blood vessels that bypass the lungs are opened and all the blood in the baby’s circulation is then able to pass through the lungs, where it undergoes gas exchange. It is a critical moment for the newborn when the lungs start to function. Failure to breathe is a common reason for birth asphyxia. Also, preterm newborns often have difficulty in getting enough oxygen after birth because their lungs are not fully matured, so gas exchange does not occur effectively.
You will learn more about neonatal jaundice in Study Session 6, and also in the Module on the Integrated Management of Newborn and Childhood Illness (IMNCI).
While in the uterus, the majority of toxic (poisonous) or waste chemicals are cleared from the baby’s blood by the placenta, which routes them to the mother’s liver, where they are broken down (the process is called detoxification). After the birth, the baby’s liver takes over this function, and detoxifies the waste chemicals produced in the body or taken in through the mouth. One of the tasks the liver has to perform is detoxifying a protein called bilirubin released when ‘old’ red blood cells are broken down. Red blood cells survive for only a short time and are then broken down and replaced. If the newborn’s liver is unable to cope with the load of ‘old’ red blood cells that need to be broken down, bilirubin builds up in the baby’s body, giving the skin a yellowish appearance. This condition is called neonatal jaundice, and is most serious when the skin appears yellow on the palms of the hands and soles of the feet.
The newborn’s kidneys also make a significant contribution to the clearance of toxic chemicals from the body, which are excreted in the urine. Immaturity in the functioning of the kidneys can also result in newborn complications as toxic chemicals build up in the body.
Imagine that you are talking to the mother of a very newborn baby and she tells you that the baby arrived a bit early. What should you immediately be concerned about?
First you need to check if the baby can feed adequately. You will probably think of the immaturity of a preterm baby’s lungs and check whether this baby shows any signs of respiratory distress. You may also think of the immaturity of the liver and kidneys and check for signs of jaundice.
You cannot assume that a successful delivery and healthy-looking mother and newborn in the immediate postnatal period will mean that they will continue in a good state. Complications may occur because of the physiological adjustments in the mother and newborn described above (which we will discuss in more detail in later study sessions in this Module), and the rapid adaptations the baby must make to life in the external environment. Therefore, you need to watch carefully for danger signs in the immediate and later postnatal period. Before sending the mother and the baby home (if they delivered at the Health Post), or before you leave both at their home after the delivery, watch them for the first six hours after the birth. If you were unable to attend the birth, visit them as soon as you can within the first 24 hours, and ideally in the first six hours.
In the first six hours, evaluate the mother for the danger signs described below:
Refer the mother urgently if you see any danger signs, take the baby too.
You should evaluate the newborn for the following danger signs in the first six hours:
Breastfeeding is described in detail in Study Session 7.
Preventing hypothermia by using the 'warm chain principle' is described in detail in Study Session 7.
The total amount of blood in an average weight newborn is only 240 ml; even 30 ml of blood loss is enough to cause shock.
During the first postnatal visit, you should also remember to:
Low birth weight and pre-term babies are the subject of Study Session 8.
Community mobilisation is defined as an action stimulated by a community, or by others, which are planned, carried out and evaluated by community members, organisations or groups, to solve community health problems. In this study session, the focus is on health problems arising during the postnatal period. Community mobilisation is a continuous and cumulative process of communication, education and organisation to build leadership and implementation capacity.
Box 1.1 summarises the main methods for community mobilisation. Our coverage is brief here because you have already met all the methods in the Module on Health Education, Advocacy and Community Mobilisation.
Posters: Well-designed posters, placed and located in the right place can facilitate messages to keep reminding people about the issue of concern.
Letter writing: This is one way of delivering health messages to literate members of the community. It gives the exact message and can be kept for future reference.
Illustrated leaflets: Pictures are a good way of getting the message to people whose level of literacy is insufficient to understand letters (Figure 1.3).
Home visiting: This is the best way of mobilising the community, because you can be sure that the message has been delivered.
Community mobilisation is based on a high level of community participation, which occurs when community members taking part in identification of problems and needs, and then plan, implement, monitor and evaluate community activities to solve the identified problem.
The fundamental principle that you always need to remember is that you are not there to ‘enforce’ community participation. Your role is to explore, to learn from community wisdom, and to educate and persuade community members to bring about the necessary changes — in this case to improve postnatal outcomes. The final word and the final decision always belong to the community.
When people are involved and participate in an activity, they develop a sense of ownership and responsibility, which helps to sustain initiatives, activities and programmes. It also has the following benefits:
The primary targets of postnatal care are the mother, her newborn baby and the father. However, there are secondary targets — the community gatekeepers who can influence decision-making that affects the mother and baby’s health. You need to involve these people right from the outset when you introduce a postnatal care service in your community. Give particular attention to involving:
Without the cooperation and collaboration of these individuals and groups it will be difficult to provide optimum postnatal care. In particular, it is essential to establish a good link and harmonise your efforts with the traditional birth attendants (TBAs). The following activities will help you to do this (Box 1.2):
Why do you think it is important to involve TBAs and local healers as described above?
They are important partners, because they know the local culture, are respected by the community, and have a lot of experience in dealing with most of the social problems arising during the postnatal period.
Imagine you are a TBA with many years of experience. A Health Extension Practitioner begins to work in your village and asks for your help. What kinds of things would make you most likely to want to cooperate and support her practice?
Of course there is no single right answer to this question, just as there is no single TBA to whom all answers will fit equally. However, you probably included some of the following points:
You learned how to conduct a community profile in Study Session 1 of the Antenatal Care Module.
Before you can provide an effective postnatal care service to your community, you should know the total population you are going to serve and how to collect vital statistics, such as births, deaths and information on migration of people into and out of the area. In addition you need to record all women in the reproductive age group (approximately 15 to 45 years), who may become pregnant in the future, and the number of currently pregnant women with their expected date of delivery.
You should also record the names and addresses of all TBAs, local healers, village drug vendors and any other private practitioners. Register all community organisations that may support you in mobilising human, financial and transportation resources, in case emergency medical referrals are required for the mother and baby. You will learn about the referral link in the final study session of this Module. All of the above information needs to be updated every four to six months.
You may not need to conduct community mobilisation separately for PNC. It should be done in an integrated and harmonised way with all other community-based maternal, neonatal and child health services. Box 1.3 summarises the activity for community mobilisation to support postnatal care.
In Study Session 1 you have learned that:
Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the questions below. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.
The following is a list of key terms used in this study session, each with a definition. Which of the definitions below are (i) fully correct, (ii) partially correct, and (iii) wrong. Write a short sentence for each of the partially correct or wrong definitions, using the term correctly.
Imagine that you are trying to convince the Ethiopian Finance Minister to put more money into postnatal health care and he wants the evidence as to why. Write a short letter outlining the key points that you would emphasise.
There are many points you could make to the Finance Minister. Here are some of the key ones:
You have done a good job persuading the Finance Minister, but he has asked the Health Minister to check that you really know what you are talking about. She asks you to list the key signs for potential complications that you should look out for in a postnatal mother and the main danger signs in the newborn baby. What would you write in your list?
Danger signs in the postnatal mother:
Key signs to look for include dehydration, a poorly contracted uterus, fresh bleeding, a drop in blood pressure and a rising pulse. Longer term dangers to be aware of include blood clots and depression.
Danger signs in the newborn:
Immediate things to check: is the baby breastfeeding properly, is the skin colour normal or yellowish, is there any fever, is the baby cold or too warm to the touch, is the breathing normal, is there any bleeding, has the baby got swollen or red eyelids? You would also check if the baby is preterm so as to know if it is at increased risk for some complications.You probably got most of these. If not, or if you can’t remember what they indicate, re-read Section 1.5.2 ‘Evaluating the newborn baby’.