On the road to universal coverage of postnatal care: considerations for a targeted postnatal care approach for at-risk mother–baby dyads in low-income and middle-income countries informed by a consultation with global experts

Abstract

IntroductionThe potential of timely, quality postnatal care (PNC) to reduce maternal and newborn mortality and to advance progress toward universal health coverage (UHC) is well-documented. Yet, in many low-income and middle-income countries, coverage of PNC remains low. Risk-stratified approaches can maximise limited resources by targeting mother–baby dyads meeting the evidence-based risk criteria which predict poor postnatal outcomes.ObjectivesTo review evidence-based risk criteria for identification of at-risk mother–baby dyads, drawn from a literature review, and to identify key considerations for their use in a risk-stratified PNC approach.Design/setting/participantsA virtual, semi-structured group discussion was conducted with maternal and newborn health experts on Zoom. Participants were identified through purposive sampling based on content and context expertise.ResultsSeventeen experts, (5 men and 12 women), drawn from policymakers, implementing agencies and academia participated and surfaced several key themes. The identified risk factors are well-known, necessitating accelerated efforts to address underlying drivers of risk. Risk-stratified PNC approaches complement broader UHC efforts by providing an equity lens to identify the most vulnerable mother–baby dyads. However, these should be layered on efforts to strengthen PNC service provision for all mothers and newborns. Risk factors should comprise context-relevant, operationalisable, clinical and non-clinical factors. Even with rising coverage of facility delivery, targeted postnatal home visits still complement facility-based PNC.ConclusionRisk-stratified PNC efforts must be considered within broader health systems strengthening efforts. Implementation research at the country level is needed to understand feasibility and practicality of clinical and non-clinical risk factors and identify unintended consequences.

Proximate and distant determinants of maternal and neonatal mortality in the postnatal period: A scoping review of data from low- and middle-income countries

“…Other factors may be infeasible for identification by CHWs (e.g., body mass index, maternal nutritional status), or may result in stigma (e.g., income, employment status, tribe/caste). As Muriuki et al [109] note, risk factors will need to be selected with consideration of relevance in the context, and feasibility for identification. Importantly, although clinical factors were not identified as part of this scoping review, any risk screening for mother-baby dyads must also include known clinical risk factors (e.g., heavy bleeding in delivery).…”

“…Although the study identified several risk factors associated with increased neonatal mortality, it is important to note that all pregnancies and deliveries are inherently high-risk events; adverse outcomes may occur even in mother-baby dyads with no identifiable risk. A targeted PNC approach should be considered only in the context of broader efforts to improve coverage and quality of PNC, so that mother-baby dyads without identifiable risk factors receive timely PNC [109]. These findings also point to risk factors that should be mitigated; comprehensive, multisectoral "upstream" efforts to reduce the prevalence of risk factors will lead to improvements in maternal and newborn outcomes.…”

Association between maternal health service utilization and under-five mortality rate in China and its provinces, 1990–2017

“…However, the effect of a one-year lag in postpartum visits on U5MR was significant and it could reduce U5MR. The potential of timely, quality postnatal visits in reducing U5MR is well documented [55,56]. In addition to neonatal diseases, the common causes of U5MR are important infections like lower respiratory infections, pneumonia [57], diarrhoea, and meningitis [58], which a relatively long duration and can be effectively prevented by means of scientific feeding and care.…”

Designing for Impact and Institutionalization: Applying Systems Thinking to Sustainable Postpartum Family Planning Approaches for First-Time Mothers in Bangladesh

“…At the community level, FWAs are supported to provide targeted postnatal HVs, prioritizing mother-baby dyads who are identified to have risk factors, including clinical and nonclinical (e.g., aged <20 years and primiparity). 30 With the targeted PNC approach, FTMs, including those who deliver at home, are prioritized for FWA outreach. FWAs distribute a mother-baby booklet written for girls and young women becoming FTMs and their male partners, and a printed invitation card that invites FTMs to access RMNCH services, including PPFP, from the closest health facility.…”