Findings from a clinical trial have revealed that mothers who received continuous standardised postpartum education and care for one-year experienced significant improvements in their knowledge of self-care and healthy behaviours.
These improvements led to enhanced maternal health outcomes, making a crucial step forward in addressing postpartum complications.
While the World Health Organization (WHO) recommends postpartum care from one hour after delivery to six weeks, recent data has highlighted a concerning trend of postpartum complications and mortality occurring beyond this period.
“As we continue to work in this area and data is coming out, we now know that a lot more women are dying beyond the six-week period,” Principal Investigator for the Focused Postpartum Care trial, Dr Joyce Yenupini Adams noted.
Sharing findings from the randomised clinical trial with the Ghana Health Service in Tamale on Wednesday, Dr. Yenupini observed that postpartum care beyond six months was “very important” if Ghana wants to improve on its maternal health outcomes.
“This late postpartum period is very important because mortality isn’t just occurring within the six weeks, it’s continuing up to one year from causes related to pregnancy and childbirth,” she said.
“Quality postpartum care is critical so that women and healthcare workers are able to identify and manage complications…postpartum education is also important so that women are empowered to be able to seek care in a timely manner and these are the reasons why we developed the Focused Postpartum Care project” she explained.
The Focused-PPC model
The Focused Postpartum Care is a model which was developed in 2020 by Savana Signatures and the ECKS Institute for Global Health through an extensive consultation with the Ghana Health Service and key stakeholders.
The project utilised a randomised controlled trial model in four facilities within the Sagnarigu municipality and provided standardised postpartum care to mothers from birth through six weeks up to one year. This care included clinical assessment, postpartum education, and peer support.
The women were recruited during the third trimester of their pregnancy and waited for them to deliver. On the back of a baseline survey, they were randomised into intervention and control groups.
“This was not selective; this was not biased. Whoever went to the intervention versus control group was by random selection, so that we can actually be able to say the results that we are seeing is due to the intervention and not due to biases,” Dr Yenupini explained.
Women in the intervention group received the focused postpartum care model whereas those in the control group received the usual care or the standard postnatal care already existent in the health facilities.
At each focused postpartum care session, participants in the intervention group were individually assessed clinically and counselled after which they met for a group session with the midwives for postpartum education.
“We ensured that women received the recommended clinical assessment within two weeks, at six weeks and continued to receive measures of vital signs up until 12 months after birth,” Dr Yenupini, who is an Assistant Professor at the ECKS Institute said.
She explained that the primary outcome of the Focused Postpartum Care project was the improve knowledge level of the women on post birth warning signs. The results showed a significant difference between the intervention and control groups in terms of their ability to identify warning signs of complications.
Results
Over time, the identification and knowledge of warning signs decreased in the control group, while they increased in the focused postpartum care group. By three months, almost 100% of participants in the focused postpartum care project were able to identify all warning signs, compared to only 30-41% in the control group, she said.
“Similarly, we also looked at women’s confidence in their ability to recognise a complication should it occur, and confidence increased in the focused postpartum group for every complication while confidence decreased in the control group for every complication,” she added.
Uptake of family planning, she said, was one of the key successes of the project as a lot more mothers in the intervention group opted for a family planning method than those in the control group.
“There was more uptake of family planning in the focused postpartum care group as opposed to the control group and by 12 months, only nine control group participants were on a family planning method as opposed to 33 participants,” Dr Yenupini revealed.
She noted that the clinical assessments of the women helped in identifying issues of high blood pressure even after six weeks, and wondered what would have happened if these women did not get postpartum care after six weeks.
“This is very important because we can see that at one to two weeks, half of the participants had high blood pressure and as time went on, we were identifying cases of high blood pressure and our midwives managing them and you can see that cases decreased over time”.
“The significance that I want to show here is that at six weeks, we still had about half of the participants having high blood pressure. If postpartum care stops at six weeks, we are missing out on managing all of these high blood pressure cases and we don’t know what the outcomes will be for women if we don’t continue to provide care,” she stated.
On that basis, the Assistant professor said care beyond that six-week timeframe “is really important”, considering that “hypertensive disorders are prevalent and are a leading cause of mortality in our setting”.
Touching on findings on postpartum depression, she said stress levels were generally lower over time in the focused postpartum care intervention groups as opposed to those in the control group.
By three months, she noted that there was “a significant difference” in the stress levels between the intervention group and the control group, which she said was maintained at six months as well.
“Similar to stress, by 3 months women who were screening positive (for depression) in the focused postpartum care group was significantly lower than women who were screening positive in the control group,” she said.
“From this first implementation, we have seen that more frequent postpartum care contact provides opportunity for identification and management of potential complications. We’ve also seen that standardised postpartum education can improve knowledge of warning signs and practices of positive health behaviours,” Dr Yenupini observed.
Consequent to these findings, she is calling for the strengthening of midwifery education and training in Ghana to make postpartum care a critical component in the curricula.
She also underscored the need to expand accessibility to postpartum care visit by extending it to a year after birth, arguing that this is critical to improving health outcomes for women during the postpartum period.
Policy brief
Executive Director for Savana Signatures who was also the co-investigator for the Focused Postpartum Care, Stephen Agbenyo, said the findings set the tone for conversation around postpartum care in Ghana.
He indicated that postpartum training for midwives was very critical, adding the “question is whether we have a postpartum care delivery training guide at the midwifery training”.
Mr. Agbenyo wondered whether the various health directorates are adequately resourced to ensure midwives receive either training or refresher courses while on the job. He underscored the need for the eight midwives who participated in the project to have cascading trainings for their colleagues to institutionalise the practices at across health facilities within the municipality.
On the way forward, Mr Agbenyo said Savana Signatures will, based on the findings, work on a policy brief which will be shared with the Ghana Health Service and other higher institutions.
“We’ll translate all the learnings into a policy brief which we’ll share with the Ghana Health Service and other higher authorities and to see how this can be crystalised into something bigger than just the four facilities that we worked with,” he said.