Early postnatal care use by postpartum mothers in Mundri East County, South Sudan

BMC Health Services Research, Volume 17, No. 1, Year 2017

Interpretation

Background: Globally, most maternal and newborn deaths are within the first week of delivery. Early postnatal-care (EPNC) visits between 2 and 7 days detects early morbidity and averts deaths. However, there is scarcity of information on use of EPNC in Mundri East County, South Sudan. This study investigated factors associated with EPNC use among postpartum mothers in Mundri East County, South Sudan. Methods: This was an analytical cross-sectional study of 385 postpartum mothers from 13 health facilities. Data was collected by structured questionnaires, entered in EpiData and analyzed with STATA at 5% significance level. Chi-squared, Fisher’s exact and Student’s t-tests were used for bivariate analysis and logistic regression for multivariable analysis. Results: The mean age of respondents was 27.9-years (standard deviation: 6.7), 276 (71.7%) were below 30-years, 163 (42.3%) were Muru ethnicity, 340 (88.3%) were single and 331 (86.1%) were unemployed. 44 (11.4%; 95% CI: 8.4-15.0) used EPNC. Poor health services access at government health facilities (Adjusted odds ratio (AOR) = 0.18; 95% CI: 0.05-0.61; P = 0.006), more than 1-h access to health facility (AOR = 0.27; 95% CI: 0.09-0.78; P = 0.015), at least secondary maternal education (AOR = 5.73; 95% CI: 1.14-28.74; P = 0.034) and receipt of PNC health education post-delivery (AOR = 3.47; 95% CI: 1.06-11.33; P = 0.004) were associated with EPNC use. Conclusions: Use of EPNC in Mundri East County, South Sudan was low. It was significantly reduced at government and inaccessible health facilities. However, it increased with receipt of PNC health education after delivery and at least secondary level of education. This study was conducted at 13 (one regional referral hospital, two county hospitals and 10 Primary Healthcare Centers (PHCC) purposively selected health facilities in Mundri East County, WES, South Sudan. In South Sudan, health services are provided at four different levels (central, state, county and community levels) each with a different diagnostic capacity and staffing requirements (including staff qualifications and responsibilities). Health services are further categorized as community care, primary health care, secondary care and specialized care. These various types of care are interlinked with a referral system [18]. Community Health Workers, Maternal and Child Health Workers and Home Health Promoters provide community healthcare at Primary Healthcare Units (PHCUs) and Primary Healthcare Centers (PHCCs) as main entry points. PHCUs provide the first level of interaction between the community and the formal health system and, provide basic preventive, promotive and curative care to about 15,000 people. In addition to services provided by PHCUs, PHCCs provide diagnostic/laboratory services and maternity care to an estimated 50,000 people. County and State Hospital levels provide secondary, comprehensive-obstetric, in-patient and surgical care to 300,000 and 500,000 people respectively [18]. According to recent data, only 48% of pregnant women in WES attend antenatal care (ANC) visits: of these, 50.3% attended the fourth ANC visits and 17% attended four or more ANC visits. In terms of human resources for health, for every 100,000 people, only three health workers (Physicians, Nurses and Midwives) are available [19]. Consequently, only 10% of pregnant mothers deliver in the hands of skilled birth attendants (SBA) like Medical Doctors, Nurses and Midwives. Mundri East County has generally been peaceful until the period May 2015 and March 2016 when armed conflict erupted and led to displacement of over 1000 people. During the displacement, lack of essential medicines at health facilities constrained health service delivery and led to death of several people in Lozoh [20]. This study used a cross-sectional design to describe factors associated with EPNC use among postpartum mothers. We sampled postpartum mothers that had live births, were 15–49 years old, 8–14 days post-delivery and that attended PNC clinics (to receive immunization, contraception and growth monitoring services) between July 20, 2016 and September 18, 2016. Three hundred eighty five respondents based on Kish and Leslie’s formula [21] within a 95% confidence limit, 5% precision and 50% conservative estimation of EPNC use were included in the analysis. The number of participants interviewed at each health facility was obtained by dividing the sample size by the total number of sampled health facilities. In each health facility, a systematic random sampling was used to establish a sampling interval by dividing the average number of postpartum mothers that attend PNC clinics by the required participant number. From the sampling interval, convenience sampling was used to select respondents. Between July and September 2016, trained and supervised Research Assistants collected data on use of PNC, socioeconomic and health services related factors by administering structured questionnaire. Interviews were conducted in quiet and conducive private room within the immunization clinic from Monday to Friday between 8.30 am-12.00 pm. All completed questionnaires were reviewed in real time for completeness and accuracy by the Research Team Lead. The primary outcome, use of EPNC was defined as the proportion of postpartum mothers that had PNC visits within 2–7 days after delivery. Socioeconomic factors assessed included education levels measured as none, primary, secondary and beyond levels; occupation measured as non-employed, formal and self-employed; household income measured as estimated monthly total earnings in Sudanese pounds; marital status assessed as single (unmarried), married (monogamous) and separated (by divorce or death); household decision making measured as who makes final decision regarding use of maternal and child health services. Health services variables assessed included level of health facility measured as PHCU, PHCC or hospital; health facility ownership measured as government or PNFP (private not for profit); use of ANC measured as the number and history of ANC visits in the last pregnancy; health education on PNC during ANC visit measured as having ever received PNC message in the last pregnancy; place of delivery measured as delivery in a health facility or a non-health facility setting (at home or on the way to a health facility); mode of delivery in the last pregnancy measured as spontaneous vaginal delivery (SVD), caesarean section or assisted delivery; SBA measured as last delivery by a Medical Doctor, Nurse or Midwife; being informed of PNC visits measured as reception of PNC messages (focused on benefits and schedules) at the time of discharge by a SBA; knowledge of postpartum complications measured as knowing some maternal postpartum complications (bleeding, offensive vaginal discharge, fever and severe abdominal pain among others) and some newborn complications (reddening of and pus discharge from the umbilical cord, restlessness, poor suckling and convulsions and so forth); time to reach the nearest health facility was taken as more or less than 1-h of reach and distance was calculated as less or more than 5-km of reach; presence of healthcare providers at the health facility was taken as having at least a health worker on duty at any time of the day and week. Data was double entered in EpiData version 3.1 (EpiData Association, Odense, Denmark) [22], checked for data quality and exported to STATA Version 12 (StataCorp, College Station, TX, USA) for univariate, bivariate and multivariate analysis using a 5% significance level. Frequencies and percentages were calculated for categorical variables, and measures of central tendency for continuous variables. Tests of associations were conducted using chi-squared test when the cell size was equal to or above five, Fisher’s exact test when the cell count was less than five, and Student’s t-test for continuous outcomes. Significant variables were considered for logistic regression analysis and examined by odds ratios (OR) with corresponding 95% confidence interval (CI) and probability values (P-values). Ethical approval was obtained from the Institutional Review Boards of Uganda Christian University (Mukono Campus), the County Health Department and Lui Hospital, South Sudan. All data collection tools were forward and backward translated and pretested outside the study area before data collection. All participants gave written or thumb printed informed consent.

AI Digest

Study Justification:

– The study aimed to investigate factors associated with the use of early postnatal care (EPNC) among postpartum mothers in Mundri East County, South Sudan.
– EPNC visits between 2 and 7 days after delivery are crucial for detecting early morbidity and preventing deaths of mothers and newborns.
– There was a lack of information on EPNC use in Mundri East County, South Sudan, which hindered the development of effective interventions to improve maternal and newborn health.

Study Highlights:

– The study included 385 postpartum mothers from 13 health facilities in Mundri East County.
– Factors associated with EPNC use were analyzed using statistical tests and logistic regression.
– The study found that only 11.4% of postpartum mothers used EPNC.
– Poor health services access at government health facilities, long travel time to reach a health facility, lower levels of maternal education, and lack of PNC health education were associated with lower EPNC use.
– EPNC use increased with receipt of PNC health education after delivery and at least a secondary level of education.

Recommendations for Lay Readers:

– Improve access to health services at government health facilities in Mundri East County.
– Reduce travel time to health facilities to encourage more postpartum mothers to seek EPNC.
– Promote maternal education, particularly at least a secondary level, to increase awareness and utilization of EPNC.
– Provide PNC health education to postpartum mothers to emphasize the importance of EPNC.

Recommendations for Policy Makers:

– Allocate resources to improve health services access at government health facilities in Mundri East County.
– Invest in infrastructure and transportation to reduce travel time to health facilities.
– Support initiatives to increase maternal education, such as scholarships or educational programs.
– Strengthen health education programs to include PNC messages and promote EPNC utilization.

Key Role Players:

– Ministry of Health: Responsible for policy development and resource allocation.
– Health Facility Administrators: Oversee the implementation of interventions at health facilities.
– Community Health Workers: Provide community healthcare and promote EPNC utilization.
– Educators: Contribute to increasing maternal education levels through formal education programs.
– Health Educators: Deliver PNC health education messages to postpartum mothers.

Cost Items for Planning Recommendations:

– Infrastructure improvement at government health facilities.
– Transportation infrastructure to reduce travel time.
– Scholarships or educational programs to support maternal education.
– Training programs for health educators.
– Printing and dissemination of PNC health education materials.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study used a cross-sectional design and collected data from a relatively large sample size of 385 postpartum mothers. The data was analyzed using appropriate statistical methods. However, the study only focused on one county in South Sudan, which limits the generalizability of the findings. To improve the strength of the evidence, future studies could consider using a longitudinal design to assess the long-term impact of early postnatal care use and include a more diverse sample from multiple counties in South Sudan.

Abstract

This study was conducted at 13 (one regional referral hospital, two county hospitals and 10 Primary Healthcare Centers (PHCC) purposively selected health facilities in Mundri East County, WES, South Sudan. In South Sudan, health services are provided at four different levels (central, state, county and community levels) each with a different diagnostic capacity and staffing requirements (including staff qualifications and responsibilities). Health services are further categorized as community care, primary health care, secondary care and specialized care. These various types of care are interlinked with a referral system [18]. Community Health Workers, Maternal and Child Health Workers and Home Health Promoters provide community healthcare at Primary Healthcare Units (PHCUs) and Primary Healthcare Centers (PHCCs) as main entry points. PHCUs provide the first level of interaction between the community and the formal health system and, provide basic preventive, promotive and curative care to about 15,000 people. In addition to services provided by PHCUs, PHCCs provide diagnostic/laboratory services and maternity care to an estimated 50,000 people. County and State Hospital levels provide secondary, comprehensive-obstetric, in-patient and surgical care to 300,000 and 500,000 people respectively [18]. According to recent data, only 48% of pregnant women in WES attend antenatal care (ANC) visits: of these, 50.3% attended the fourth ANC visits and 17% attended four or more ANC visits. In terms of human resources for health, for every 100,000 people, only three health workers (Physicians, Nurses and Midwives) are available [19]. Consequently, only 10% of pregnant mothers deliver in the hands of skilled birth attendants (SBA) like Medical Doctors, Nurses and Midwives. Mundri East County has generally been peaceful until the period May 2015 and March 2016 when armed conflict erupted and led to displacement of over 1000 people. During the displacement, lack of essential medicines at health facilities constrained health service delivery and led to death of several people in Lozoh [20]. This study used a cross-sectional design to describe factors associated with EPNC use among postpartum mothers. We sampled postpartum mothers that had live births, were 15–49 years old, 8–14 days post-delivery and that attended PNC clinics (to receive immunization, contraception and growth monitoring services) between July 20, 2016 and September 18, 2016. Three hundred eighty five respondents based on Kish and Leslie’s formula [21] within a 95% confidence limit, 5% precision and 50% conservative estimation of EPNC use were included in the analysis. The number of participants interviewed at each health facility was obtained by dividing the sample size by the total number of sampled health facilities. In each health facility, a systematic random sampling was used to establish a sampling interval by dividing the average number of postpartum mothers that attend PNC clinics by the required participant number. From the sampling interval, convenience sampling was used to select respondents. Between July and September 2016, trained and supervised Research Assistants collected data on use of PNC, socioeconomic and health services related factors by administering structured questionnaire. Interviews were conducted in quiet and conducive private room within the immunization clinic from Monday to Friday between 8.30 am-12.00 pm. All completed questionnaires were reviewed in real time for completeness and accuracy by the Research Team Lead. The primary outcome, use of EPNC was defined as the proportion of postpartum mothers that had PNC visits within 2–7 days after delivery. Socioeconomic factors assessed included education levels measured as none, primary, secondary and beyond levels; occupation measured as non-employed, formal and self-employed; household income measured as estimated monthly total earnings in Sudanese pounds; marital status assessed as single (unmarried), married (monogamous) and separated (by divorce or death); household decision making measured as who makes final decision regarding use of maternal and child health services. Health services variables assessed included level of health facility measured as PHCU, PHCC or hospital; health facility ownership measured as government or PNFP (private not for profit); use of ANC measured as the number and history of ANC visits in the last pregnancy; health education on PNC during ANC visit measured as having ever received PNC message in the last pregnancy; place of delivery measured as delivery in a health facility or a non-health facility setting (at home or on the way to a health facility); mode of delivery in the last pregnancy measured as spontaneous vaginal delivery (SVD), caesarean section or assisted delivery; SBA measured as last delivery by a Medical Doctor, Nurse or Midwife; being informed of PNC visits measured as reception of PNC messages (focused on benefits and schedules) at the time of discharge by a SBA; knowledge of postpartum complications measured as knowing some maternal postpartum complications (bleeding, offensive vaginal discharge, fever and severe abdominal pain among others) and some newborn complications (reddening of and pus discharge from the umbilical cord, restlessness, poor suckling and convulsions and so forth); time to reach the nearest health facility was taken as more or less than 1-h of reach and distance was calculated as less or more than 5-km of reach; presence of healthcare providers at the health facility was taken as having at least a health worker on duty at any time of the day and week. Data was double entered in EpiData version 3.1 (EpiData Association, Odense, Denmark) [22], checked for data quality and exported to STATA Version 12 (StataCorp, College Station, TX, USA) for univariate, bivariate and multivariate analysis using a 5% significance level. Frequencies and percentages were calculated for categorical variables, and measures of central tendency for continuous variables. Tests of associations were conducted using chi-squared test when the cell size was equal to or above five, Fisher’s exact test when the cell count was less than five, and Student’s t-test for continuous outcomes. Significant variables were considered for logistic regression analysis and examined by odds ratios (OR) with corresponding 95% confidence interval (CI) and probability values (P-values). Ethical approval was obtained from the Institutional Review Boards of Uganda Christian University (Mukono Campus), the County Health Department and Lui Hospital, South Sudan. All data collection tools were forward and backward translated and pretested outside the study area before data collection. All participants gave written or thumb printed informed consent.

Materials

N/A

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health in Mundri East County, South Sudan:

1. Mobile Health Clinics: Implementing mobile health clinics that can travel to remote areas and provide essential maternal health services, including early postnatal care, to women who may not have easy access to health facilities.

2. Telemedicine: Introducing telemedicine services that allow healthcare providers to remotely assess and monitor postpartum mothers, providing guidance and support through virtual consultations.

3. Community Health Workers: Expanding the role of community health workers to include providing early postnatal care services, such as health education, monitoring vital signs, and identifying potential complications, within their communities.

4. Health Education Programs: Developing targeted health education programs that specifically focus on the importance of early postnatal care and its benefits, aiming to increase awareness and encourage more women to seek these services.

5. Strengthening Health Facilities: Improving the infrastructure and resources of health facilities in Mundri East County, including government health facilities, to ensure better access to quality maternal health services, including early postnatal care.

6. Transportation Support: Providing transportation support, such as ambulances or transportation vouchers, to pregnant and postpartum women who may face challenges in reaching health facilities for early postnatal care.

7. Collaboration with Traditional Birth Attendants: Collaborating with traditional birth attendants to ensure they are trained and equipped to provide basic early postnatal care services, while also promoting timely referral to health facilities when necessary.

8. Maternal Health Incentives: Introducing incentives, such as conditional cash transfers or vouchers, to encourage women to seek early postnatal care services, thereby increasing utilization rates.

9. Strengthening Referral Systems: Improving the referral systems between different levels of healthcare facilities, ensuring smooth and timely transfers of postpartum mothers who require higher levels of care.

10. Data Monitoring and Evaluation: Establishing a robust data monitoring and evaluation system to track the utilization of early postnatal care services, identify gaps, and inform evidence-based decision-making for further improvements.

It is important to note that the implementation of these innovations should be context-specific and consider the unique challenges and resources available in Mundri East County, South Sudan.

AI Innovations Description

Based on the description provided, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Improve health services access at government health facilities: This can be done by increasing the availability of essential medicines and supplies, ensuring adequate staffing levels, and improving the overall quality of care provided at government health facilities.

2. Reduce travel time to health facilities: Since longer travel time was associated with lower utilization of early postnatal care (EPNC), efforts should be made to reduce the time it takes for postpartum mothers to reach the nearest health facility. This can be achieved by establishing more health facilities in remote areas, improving transportation infrastructure, and providing transportation subsidies or incentives for postpartum mothers to access care.

3. Increase health education on postnatal care: Providing postpartum mothers with comprehensive health education on the importance of early postnatal care and the potential complications that can arise during the postpartum period can help increase utilization. This can be done through antenatal care visits, community health education programs, and the use of mobile health technologies to deliver targeted health messages.

4. Promote maternal education: The study found that postpartum mothers with at least secondary level of education were more likely to utilize EPNC. Therefore, efforts should be made to promote and support maternal education, particularly in areas with low educational attainment rates. This can be done through initiatives such as adult literacy programs, scholarships for girls, and community-based education campaigns.

5. Strengthen the referral system: Since different levels of health facilities provide different levels of care, it is important to strengthen the referral system to ensure that postpartum mothers are able to access the appropriate level of care when needed. This can be achieved through training and capacity building for health workers, improving communication and coordination between different levels of care, and ensuring that referral processes are well-defined and easily accessible for postpartum mothers.

By implementing these recommendations, it is expected that access to maternal health, particularly early postnatal care, can be improved in Mundri East County, South Sudan.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthen health services at government health facilities: Address the issues of poor health services access by improving the quality and availability of healthcare services at government health facilities in Mundri East County, South Sudan. This can be done by increasing the number of healthcare providers, ensuring the availability of essential medicines and supplies, and improving the overall infrastructure and equipment.

2. Reduce travel time to health facilities: Implement strategies to reduce the time it takes for postpartum mothers to reach the nearest health facility. This can be achieved by establishing more primary healthcare units (PHCUs) and primary healthcare centers (PHCCs) in the community, ensuring that these facilities are easily accessible, and providing transportation options for those who live far from health facilities.

3. Increase health education on postnatal care: Provide comprehensive health education on the importance of early postnatal care (EPNC) to postpartum mothers during antenatal care (ANC) visits. This should include information on the benefits of EPNC, the recommended timing of visits, and the potential complications that can be detected and treated early through EPNC.

4. Improve maternal education: Promote and support maternal education, particularly at least secondary level of education. Educated mothers are more likely to understand the importance of EPNC and seek healthcare services for themselves and their newborns.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify the key indicators that will be used to measure the impact of the recommendations. This could include the percentage of postpartum mothers using EPNC, the average travel time to the nearest health facility, the availability of healthcare providers at health facilities, and the level of health education on postnatal care.

2. Collect baseline data: Gather data on the current status of the indicators before implementing the recommendations. This can be done through surveys, interviews, and data collection from health facilities and other relevant sources.

3. Implement the recommendations: Put the recommendations into action, making the necessary changes to strengthen health services, reduce travel time, increase health education, and promote maternal education.

4. Monitor and evaluate: Continuously monitor and evaluate the impact of the recommendations on the defined indicators. This can be done through regular data collection, surveys, and interviews with postpartum mothers and healthcare providers.

5. Analyze the data: Analyze the collected data to assess the changes in the indicators after implementing the recommendations. This can involve statistical analysis, comparing the baseline data with the post-implementation data.

6. Draw conclusions and make adjustments: Based on the analysis, draw conclusions about the impact of the recommendations on improving access to maternal health. Identify any areas that may require further adjustments or interventions to achieve the desired outcomes.

7. Repeat the process: Continuously repeat the monitoring and evaluation process to track progress and make further improvements as needed. This will help ensure that access to maternal health continues to improve over time.

Authors & Co-Authors

Statistics:

Citations: 21

Authors: 3

Identifiers:

DOI: 10.1186/s12913-017-2402-1

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce

Study Countries:

Multi-Countries, South Sudan, Sudan, Uganda

Study Design:

Case-Control Study, Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Female