Immediate postnatal care following childbirth in Ugandan health facilities: An analysis of Demographic and Health Surveys between 2001 and 2016

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Study Justification:
The study titled “Immediate postnatal care following childbirth in Ugandan health facilities: An analysis of Demographic and Health Surveys between 2001 and 2016” aims to address the insufficient progress in reducing maternal and neonatal mortality in Uganda. The first 24 hours after childbirth is a critical period for mothers and babies, yet less than 50% of women in Uganda reported receiving immediate postnatal care. This study analyzes the coverage, changes over time, and determinants of immediate postnatal care in Uganda after facility births.
Study Highlights:
1. Between 2006 and 2016, births in healthcare facilities increased from 44.6% to 75.2%, and coverage of immediate postnatal care increased from 35.7% to 65.0%.
2. The majority of first postnatal checks occurred between 1 and 4 hours postpartum, with the median time reducing from 4 hours to 1 hour.
3. Women who had a caesarean section birth, were exposed to mass media, had their baby weighed at birth, and received antenatal care with 4+ visits were more likely to receive immediate postnatal care.
Recommendations for Lay Readers and Policy Makers:
1. To ensure universal coverage of high-quality care during the immediate postnatal period, maternal and newborn services should be integrated and actively involve mothers and their partners.
2. Efforts should be made to increase the coverage of immediate postnatal care, especially among women who give birth in healthcare facilities.
3. Health education campaigns should be conducted to raise awareness about the importance of immediate postnatal care and its benefits for both mothers and babies.
4. Policies should be implemented to improve access to healthcare facilities and ensure that healthcare professionals are available to provide postnatal care within the recommended timeframe.
Key Role Players:
1. Ministry of Health: Responsible for developing and implementing policies related to maternal and newborn healthcare.
2. Healthcare Facilities: Provide the necessary infrastructure and resources for delivering immediate postnatal care.
3. Healthcare Professionals: Including doctors, nurses, midwives, and medical assistants/clinical officers who provide postnatal care services.
4. Community Health Workers: Play a crucial role in educating and mobilizing communities to seek immediate postnatal care.
5. Non-Governmental Organizations (NGOs): Collaborate with the government to support and implement programs aimed at improving postnatal care services.
Cost Items for Planning Recommendations:
1. Training and Capacity Building: Budget for training healthcare professionals on providing high-quality immediate postnatal care.
2. Infrastructure and Equipment: Allocate funds for improving healthcare facilities, including the availability of essential equipment and supplies.
3. Health Education Campaigns: Set aside a budget for developing and implementing awareness campaigns targeting both healthcare providers and the general population.
4. Community Engagement: Allocate resources for engaging community health workers and supporting their activities in promoting immediate postnatal care.
5. Monitoring and Evaluation: Include funds for monitoring and evaluating the implementation and impact of the recommendations.
Please note that the cost items provided are general categories and not actual cost estimates. The actual cost will depend on the specific context and implementation strategies.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, as it is based on an analysis of the Ugandan Demographic and Health Surveys between 2001 and 2016. The study includes a large sample size of 12,872 mothers and presents descriptive statistics and logistic regression analysis. The findings show an increase in facility-based births and coverage of immediate postnatal care over time. The study also identifies factors associated with receiving immediate postnatal care. To improve the evidence, the study could consider conducting a longitudinal study to track changes in immediate postnatal care over a longer period and include qualitative research to gain a deeper understanding of the barriers and facilitators to receiving postnatal care in Uganda.

Introduction Progress in reducing maternal and neonatal mortality, particularly in sub-Saharan Africa, is insufficient to achieve the Sustainable Developmental Goals by 2030. The first 24 hours following childbirth (immediate postnatal period), where the majority of morbidity and mortality occurs, is critical for mothers and babies. In Uganda,<50% of women reported receiving such care. This paper describes the coverage, changes over time and determinants of immediate postnatal care in Uganda after facility births between 2001 and 2016. Methods We analysed the 2006, 2011 and 2016 Ugandan Demographic and Health Surveys, including women 15-49 years with most recent live birth in a healthcare facility during the survey 5-year recall period. Immediate postnatal care coverage and changes over time were presented descriptively. Multivariable logistic regression was used to examine determinants of immediate postnatal care. Results Data from 12 872 mothers were analysed. Between 2006 and 2016, births in healthcare facilities increased from 44.6% (95% CI: 41.9% to 47.3%) to 75.2% (95% CI: 73.4% to 77.0%) and coverage of immediate maternal postnatal care from 35.7% (95% CI 33.4% to 38.1%) to 65.0% (95% CI: 63.2% to 66.7%). The majority of first checks occurred between 1 and 4 hours post partum; the median time reduced from 4 hours to 1 hour. The most important factor associated with receipt of immediate postnatal care was women having a caesarean section birth adjusted OR (aOR) 2.93 (95% CI: 2.28 to 3.75). Other significant factors included exposure to mass media aOR 1.38 (95% CI: 1.15 to 1.65), baby being weighed at birth aOR 1.84 (95% CI: 1.58 to 2.14) and receipt of antenatal care with 4+Antenatal visits aOR 2.34 (95% CI: 1.50 to 3.64). Conclusion In Uganda, a large gap in coverage remains and universal immediate postnatal care has not materialised through increasing facility-based births or longer length of stay. To ensure universal coverage of high-quality care during this critical time, we recommend that maternal and newborn services should be integrated and actively involve mothers and their partners.

Household surveys are the main source of data used within maternal health to compare coverage trends and inequalities both within and between countries.26 The Demographic and Health Surveys (DHS) are cross-sectional nationally representative household surveys, usually covering 5000–30 000 households. They collect data from women in reproductive age (15–49 years) about births and the use of reproductive and maternal care. We used the DHS collected in Uganda in 2006, 2011 and 2016. The DHS use a multilevel cluster sampling survey design; individual women’s survey weights, and the elements of stratification and clustering are needed in analysis to adjust for this design and for non-response. The most recent live birth within a recall period of 5 years to women aged 15–49 at the time of survey, was included in the analysis, if the birth occurred in a health facility. Data from prior births or from those outside of a facility were excluded (figure 1). This resulted in a total of 12 872 eligible mothers included for analysis. Study population flow diagram. Our main outcome is the women’s report of receiving immediate postnatal health check by a healthcare professional within 24 hours of childbirth while still in the healthcare facility. This was a binary outcome (yes/no). This variable was created with a conceptual link to the WHO Postnatal care recommendations, which state that all women giving birth in healthcare facilities and their babies should remain in the health facility for a minimum of 24 hours following uncomplicated vaginal childbirth, and receive frequent routine postnatal care checks during this period.15 We used four variables to construct this outcome, based on separate questions that women were asked: (1) whether the woman received a postnatal check while still in the facility; (2) length of stay of woman in the facility where the birth took place; (3) timing of the first postnatal check in the facility where birth took place and (4) cadre of professional conducting the first postnatal check on mother. As per the WHO recommendations, we would expect optimal immediate postnatal care to be 100% coverage. There were no differences in the question wording used in the three surveys. Women who reported a stay in the facility of under 24 hours after childbirth needed to have received such a check before discharge. Among women who remained at the facility for 24 hours or more, we used the timing of the postnatal check variable to determine whether the first postnatal health check occurred within 24 hours of childbirth. We categorised health professionals as: doctor, nurse/midwife and medical assistant/clinical officer. To analyse the timing of the postnatal checks within 24 hours among those who received one, we used the women’s response to the question on timing of the first postnatal check in the facility where birth took place and constructed the following categories: (1)1). Antenatal care (ANC) in pregnancy was thought to reflect both perceived need and characteristics of healthcare facility. As those women who received facility based ANC were likely to give birth in that same facility. This dimension was examined by categorising the number of ANC visits during the pregnancy (no ANC, 1–3 visits, 4+visits). Health knowledge and exposure to mass media were thought to reflect the perceived need and sociodemographic factors. There were no questions in the DHS that assessed health knowledge and this dimension could therefore not be analysed further. Exposure to mass media was explored through the variables; any use of television, internet, newspaper and radio (or not) at the time of the survey. We considered eight sociodemographic factors for inclusion into the model. Maternal age group at birth of baby (in 5-year age groups), marital status (married or cohabiting at time of survey or not), highest maternal education level (no education, primary education, secondary and higher education) and ethnicity (Christian, other religions) were assessed. The boundaries of districts and regions changed over the ten-year period covered by the three DHS and were not identical. We, therefore, constructed four larger zones (Eastern, Western, Northern, Central—see online supplemental material 1) which are consistent over time, as done previously.6 bmjgh-2020-004230supp001.pdf Family composition was assessed by number of persons (<4, 4–5, 6+ persons) and number of children under the age of 5 years (0–1, 2–3, 4+) in the woman’s household. Women’s occupation was not examined, as data in DHS pertained to the time of the survey and not at the time of index birth. Household wealth quintile, place of residence (urban vs rural) and the woman’s autonomy were thought to reflect both socio-demographic factors and access to healthcare factors. Household wealth quintiles were provided in the dataset and constructed using principal component analysis of household assets using an established method.6 The dimension of financial autonomy was explored with the binary variable of the woman having a bank account or not. Further exploration of autonomy to healthcare and finances was conducted in sensitivity analysis among married women through the variables who makes decisions about healthcare and finances (respondent alone, respondent and male partner, male partner alone, other). Male partner’s highest education level (no education, primary education, secondary/higher education) was explored further in subgroup analysis among women married at the time of survey. We identified five dimensions related to characteristics of the healthcare facility where the birth occurred. We categorised the sector of the facility as public (government hospital, government health centre, other public sector) or private (private hospital/clinic, other private medical sector). Assistance with the birth was captured by considering the highest cadre listed (doctor/non-physician clinicians, nurse/midwife, other/none). Staff-related factors were conceptually important, but not available on DHS. The dimension patient perceived quality of care was not directly asked within the DHS and no proxies for this dimension could be found. There were no direct variables that asked women to recall the content of their postnatal care. We used the variable of whether the woman reported that the baby was weighed (or not) as a proxy for this dimension as it is reflective of the available staffing, procedures and resources. We were able to assess one dimension—social support and network—for access to healthcare. This dimension was captured by the two created variables: number of persons (<4, 4–5, 6+ persons) and number of children under the age of 5 in the woman’s household (0–1, 2–3, 4+). The distance of the house to the nearest facility or the facility where the birth occurred, or transport/road facilities are not captured on the DHS. Ability to pay for healthcare was thought to reflect both characteristics of healthcare facility and access to healthcare. The variable of whether the woman was covered by health insurance or not was used to reflect this dimension. All analyses were conducted in STATA V.16 SE. Analysis included descriptive statistics of demographic characteristics of women who gave birth in health facilities on all three surveys. Among women who gave birth in health facilities, we computed the percentage who reported receiving immediate maternal postnatal care. Among women with such a check, we described the distribution of the timing of the first check. We calculated the percentage of babies born in health facilities receiving a postnatal check within 24 hours, disaggregated by type of facility. For the 2016 survey, we conducted an analysis of mother–baby dyads and calculated the percentage receiving immediate postnatal care within 24 hours while still in healthcare facilities for mother only, baby only, both and neither. Additionally, we used logistic regression to explore the crude associations between factors outlined in the conceptual framework and the woman’s receipt of immediate postnatal care by a health professional in the facility. A multivariable logistic regression model was created by analysing each individual variable and excluding those that were collinear with existing variables. This enabled the multivariable model to be a reflection of the conceptual model. Two sensitivity analyses using crude and multivariable logistic regression were conducted. First, among the subsample of women married/cohabiting at the time of survey, we additionally included highest level of male partner education, and autonomy with finances and healthcare. Among women with previous children, the model included previous baby death. We used the survey set command to adjust all analyses for survey sampling design and non-response using individual sampling weights, stratification and clustering. There were low levels of missing data in the variables used. We describe how missing values were handled in online supplemental material 2. bmjgh-2020-004230supp002.pdf It was not appropriate or possible to involve patients or the public in the design, or conduct, or reporting, or dissemination plans of our research.

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Based on the provided description, here are some potential innovations that could be recommended to improve access to maternal health:

1. Integration of maternal and newborn services: To ensure comprehensive care during the immediate postnatal period, it is recommended to integrate maternal and newborn services. This would involve providing simultaneous care for both the mother and the baby, addressing their specific needs and ensuring continuity of care.

2. Active involvement of mothers and their partners: To improve access to immediate postnatal care, it is important to actively involve mothers and their partners in decision-making and care processes. This could include providing education and information about the importance of postnatal care, encouraging participation in decision-making, and promoting shared responsibility for the health and well-being of both the mother and the baby.

3. Strengthening healthcare facilities: To enhance access to immediate postnatal care, it is crucial to strengthen healthcare facilities. This could involve improving infrastructure, ensuring availability of skilled healthcare professionals, and providing necessary resources and equipment for postnatal care. Additionally, efforts should be made to improve the quality of care provided in healthcare facilities, including adherence to recommended postnatal care guidelines.

4. Increasing awareness through mass media: Exposure to mass media has been identified as a significant factor associated with receiving immediate postnatal care. Therefore, innovative approaches could be implemented to increase awareness about the importance of postnatal care through mass media channels such as television, radio, newspapers, and the internet. This could include targeted campaigns, educational programs, and the use of digital platforms to disseminate information.

5. Addressing financial barriers: Financial autonomy and ability to pay for healthcare have been identified as important factors influencing access to postnatal care. To address this, innovative financing mechanisms could be explored, such as health insurance schemes or subsidies for postnatal care services. Additionally, efforts should be made to ensure that postnatal care services are affordable and accessible to all women, regardless of their financial situation.

These recommendations are based on the findings and analysis presented in the provided description and aim to address the gaps and challenges identified in improving access to immediate postnatal care in Uganda.
AI Innovations Description
Based on the analysis of the Demographic and Health Surveys in Uganda between 2001 and 2016, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Integration of maternal and newborn services: To ensure universal coverage of high-quality care during the immediate postnatal period, it is recommended to integrate maternal and newborn services. This means that the care provided to mothers should also include comprehensive care for their newborns. By integrating these services, healthcare facilities can ensure that both mothers and babies receive the necessary care and support during this critical time.

2. Active involvement of mothers and their partners: It is important to actively involve mothers and their partners in the decision-making process and care planning. This can be done through education and counseling sessions, where mothers and their partners are informed about the importance of immediate postnatal care and their role in ensuring the health and well-being of both the mother and the baby. By involving them in the care process, healthcare providers can empower mothers and their partners to take an active role in their own healthcare and make informed decisions.

3. Strengthening healthcare infrastructure and resources: To improve access to immediate postnatal care, it is crucial to strengthen healthcare infrastructure and ensure the availability of necessary resources. This includes increasing the number of healthcare facilities, improving their capacity to provide postnatal care, and ensuring the availability of skilled healthcare professionals. Additionally, resources such as medical equipment, supplies, and medications should be adequately provided to meet the needs of mothers and newborns.

4. Enhancing health knowledge and exposure to mass media: To increase awareness and knowledge about the importance of immediate postnatal care, it is recommended to enhance health knowledge and exposure to mass media. This can be done through targeted health education campaigns, community outreach programs, and the use of various media channels such as television, radio, newspapers, and the internet. By improving health knowledge and exposure to information, mothers and their families can make informed decisions and seek timely postnatal care.

By implementing these recommendations, it is expected that access to maternal health will be improved, leading to better health outcomes for both mothers and newborns in Uganda.
AI Innovations Methodology
Based on the provided description, here are some potential recommendations for improving access to maternal health:

1. Integration of maternal and newborn services: To ensure universal coverage of high-quality care during the immediate postnatal period, it is recommended to integrate maternal and newborn services. This means actively involving mothers and their partners in the care process and ensuring that both mothers and babies receive the necessary postnatal care.

2. Increase exposure to mass media: The study found that exposure to mass media was a significant factor associated with receiving immediate postnatal care. Therefore, it is recommended to increase exposure to mass media, such as television, internet, newspapers, and radio, to improve awareness and knowledge about the importance of postnatal care.

3. Improve access to antenatal care: The study also found that women who received antenatal care with 4 or more visits were more likely to receive immediate postnatal care. Therefore, efforts should be made to improve access to antenatal care services, ensuring that women have regular and adequate visits during pregnancy.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the indicators: Identify specific indicators that measure access to maternal health, such as the percentage of women receiving immediate postnatal care, the percentage of facility-based births, and the timing of the first postnatal check.

2. Collect baseline data: Gather data on the current status of access to maternal health, using existing sources such as household surveys or health facility records. This will serve as the baseline for comparison.

3. Develop a simulation model: Create a simulation model that incorporates the identified recommendations and their potential impact on the selected indicators. This model should consider factors such as population demographics, healthcare infrastructure, and resource availability.

4. Input data and parameters: Input the baseline data into the simulation model, along with relevant parameters related to the recommendations. For example, the model could include data on the current level of exposure to mass media and the expected increase in exposure based on the recommendation.

5. Run simulations: Run the simulation model multiple times, adjusting the parameters related to the recommendations to simulate different scenarios. For example, simulate the impact of increasing exposure to mass media by 10%, 20%, and 30% on the percentage of women receiving immediate postnatal care.

6. Analyze results: Analyze the results of the simulations to determine the potential impact of the recommendations on improving access to maternal health. Compare the different scenarios to identify the most effective strategies.

7. Refine and validate the model: Refine the simulation model based on the analysis of the results and validate it using additional data sources or expert input. This will ensure that the model accurately represents the real-world situation and can be used for future predictions.

By following this methodology, policymakers and healthcare professionals can gain insights into the potential impact of different recommendations on improving access to maternal health. This information can guide decision-making and resource allocation to achieve better maternal health outcomes.

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