POLICY BRIEF: Improve availability and provision of quality postpartum care services at both facility and community levels to reduce occurrence of post-partum maternal and neonatal infections in Uganda

Summary

Post-partum infections have been associated with severe maternal and newborn morbidity, death, and long-term disabilities. Prompt postpartum care services (PPC) for both the mother and the new-born is important in identifying and treating any complications that may arise from child birth, as well as to provide the mother with important information on caring for herself and her new-born. Postpartum care has remained relatively neglected in many interventions designed to improve maternal and neonatal health. Postnatal care coverage (% mothers) in Uganda is still low and was reported at 54.3 % in 2016, according to the World Bank collection of development indicators. According to the Uganda demo-graphic health survey 2016 report, 54% of women reported to have received a postnatal check during the first 2 days after birth. The current government of Uganda policy regarding post-partum care services is for mothers to receive PPC when they bring their infants for immunization. However, this policy has not been implemented well and it is not clear how this policy has been adhered too. Although immunization use has continued to rise, it is noted that many mothers do not receive any post- partum care services even when they do bring their children for immunization. Also this policy does not include strategies to be implemented at community levels. Improving the availability and provision of quality postpartum care services at both facility and community levels can reduce occurrence of post-partum maternal and neonatal infections in Uganda.

Background

Postpartum infections are the major causes of maternal preventable morbidity and mortality worldwide and also increases the length of patient hospitalization and hospital expenses(1). Post-partum infections usually occurs after the first 24 hours and within the first ten days following delivery(2). A large pro-portion of maternal and neonatal deaths occur during the first 48 hours after delivery. Thus, prompt postnatal care (PNC) for both the mother and the child is important to treat any complications that arise from the delivery, as well as to provide the mother with important information on caring for herself and her child (3).
Descriptive data analysis of a five-year period (2013 -2017), indicates that over the entire study period, 16,654 facility based new admissions due to maternal sepsis were reported in Uganda. The average incidence in maternal sepsis admissions over the five years was 34/10000 live births. The annual incidence increased gradually from 28/10000 live births in January 2013 to 50/10000 live births in December 2017. There was a 12% annual increase in admissions due to maternal sepsis from 2013 (2131 cases) to 2017 (5213 cases) (OR=1.12, 95%CI = 1.01 -1.24. The cumulative incidence in maternal sepsis admissions was highest in the northern region (199/10000 live births) and low-est in the central region (146/10000 live births).

Context and Importance of the Problem

Approximately five million cases of pregnancy-related infections occur every year globally, and approximately 75,000 result in death(3). Post-partum infections contribute 10% to the preventable maternal mortality in low-income countries(4). Apart from severe morbidity and death, women who experience post-partum infections are also prone to long-term disabilities such as chronic pelvic pain, fallopian tube blockage and secondary infertility(5). Maternal infections before or during childbirth are also associated with an estimated 1 million newborn deaths annually. Neonatal sepsis is often strictly connected to infection of the maternal genital tract during labour and maternal conditions after birth(6). In a retrospective study conducted to find out causes and predictors of maternal deaths at Mbarara regional referral hospital in Uganda, puerperal sepsis accounted for 31% of maternal deaths, making it the most common cause of maternal mortality at that facility. Around 1.5 million annual neonatal deaths occur in the first week of life(7).

Critique of Policy Options

Globally, the most common intervention for preventing morbidity and mortality related to maternal infection is the use of antibiotics for prophylaxis and treatment(8). However, the misuse of antibiotics for obstetric conditions and procedures that are thought to carry risks of maternal infection is common in clinical practice(9). Such inappropriate use of antibiotics among women giving birth has implications on global efforts to contain the emergence of resistant bacteria strains and, consequently, on global health. Therefore, appropriate guidance for health professionals and policy-makers on the need for antibiotics – and the type of antibiotics – for the prevention and treatment of maternal prepartum infections would align with the WHO strategy to reduce antibiotic resistance and, ultimately, improve maternal and newborn out-comes.
World Health Organization (WHO) recommends standard infection prevention and control measures that should be ob-served in the provision of maternity care to optimize the effects of interventions recommended in this guideline. These measures should include: Avoidance of infection by identifying and correcting predisposing factors to infection, clinical monitoring of women for signs of infection throughout labour and the postpartum period and early detection of infection by laboratory investigation as needed, reduction of nosocomial trans-mission of infections by barrier nursing of women with peripartum infections and care should be organized in a way that facilitates staff behavioral change and encourages compliance with the hospital infection control measures (10).
In Uganda, the availability and provision of quality post- par-tum care services at both facility and community levels is still poor. The government policy regarding post-partum care services is for mothers to receive PPC when they bring their infants for immunization. However, this policy has not been implemented well and it is not clear how this policy has been adhered too. Although immunization use has continued to rise, it is noted that many mothers do not receive any post- par-tum care services even when they do bring their children for immunization(10). The policy does not include strategies to be implemented at community levels. Therefore implementing strategies to improve availability and provision of quality post-partum care services at both facility and community levels can help in reducing the incidence of post-partum infections.

Policy recommendations

Increasing the availability and provision of quality postpartum services at facility and community level can reduce occurrence of postpartum infections. This includes the introduction of routine postpartum home visits, strengthening postpartum out-reach services, integration of postpartum services for the moth-er in child immunisation clinics, distribution of postpartum care guidelines among health workers, upgrading postpartum care knowledge and skills through training and microbiological confirmation of infection or infectious outcomes.

Conclusion and Recommendations

Post-partum infections are preventable. The government of Uganda through the ministry of health needs to strengthen strategies that can improve the availability and provision of quality postpartum services at facility and community level to reduce occurrence of postpartum infections.

References

1. van Dillen J, Zwart J, Schutte J, van Roosmalen J. Maternal sepsis: epidemiology, etiology and outcome. Curr Opin Infect Dis. 2010;23(3):249–254.
2. Sweet RL, Ledger WJ. Puerperal infectious morbidity: a two-year review. Am J Obstet Gynecol. 1973;117(8):1093–1100.
3. Miller AE, Morgan C, Vyankandondera J. Causes of puerperal and neonatal sepsis in resource-constrained settings and advocacy for an integrated community-based postnatal approach. Int J Gynecol Obstet. 2013;123(1):10–15.
4. Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. The lancet. 2006;367(9516):1066–1074.
5. Hardee K, Gay J, Blanc AK. Maternal morbidity: neglect-ed dimension of safe motherhood in the developing world. Glob Public Health. 2012;7(6):603–617.
6. Lawn JE, Cousens S, Zupan J, Team LNSS. 4 million neonatal deaths: when? Where? Why? The lancet. 2005;365(9462):891–900.