Up to 45% of all maternal deaths occur within one day of delivery, 65% within the first week and 80% within the first two weeks after birth. Thus, during the first 24 hours postpartum and the first week after birth, women are at highest risk for maternal death. The risk remains significant in the second week postpartum as well. Hemorrhage, pregnancy-induced hypertension (PIH) and sepsis are the most common causes of early postpartum maternal death. As much as 30% of all PIH occurs in the first days postpartum. The period of greatest risk for hemorrhage and PIH is during the first day and drops off steeply after that. Careful attention is needed during the first 4 to 6 hours, when postpartum hemorrhage is most likely to occur. Most deaths from sepsis occur during the second week after delivery.

The early postpartum period is critical to newborn survival as well. Neonatal mortality now accounts for approximately two thirds of the eight million annual deaths worldwide in children under one year of age. 98% of all newborn deaths occur in developing countries, mainly Africa and Asia. The first week of life is a particularly vulnerable period, when 50-70% of fatal and life-threatening newborn illnesses occur. Most of these newborn deaths are due to sepsis, asphyxia and problems associated with low birth weight.

Programs should emphasize routine skilled care for new mothers and newborns that focuses on early detection of complications and prompt referral, in addition to the "fortieth day" postpartum visit. It is a particular challenge to develop early postpartum care programs that can deliver this lifesaving care in resource-poor rural areas where a skilled provider rarely attends even the births.

Option 2: create or strengthen a cadre of informed, community early postpartum visitors who can make several visits into the home of new mothers in the two weeks after birth to check for danger signs in both mother and newborn.

Option 3: create an early postpartum care station in the community, an important option if households are resistant to an external visitor entering the home during the culturally-sanctioned isolation during the first few days after birth. In those cases, a "linkworker" at the care station could evaluate, refer and accompany the woman or newborn to skilled care.

• Identify factors that contribute to patterns of early postpartum care seeking behavior among recently delivered women; and explore the factors underlying careseeking decisionmaking during the early postpartum period in remote rural Guinea;
• Test the acceptability among families, community members and skilled care providers of the concept of introducing home visitors as "linkworkers" to skilled early postpartum care; and to determine their preferred EPPC option (described above);
• Test the feasibility and effectiveness of using community interviewers to conduct qualitative research; and
• Actively involve community members in designing a locally appropriate "community-negotiated" early postpartum care intervention.

The current maternal mortality ratio in Guinea is estimated at 528 per 100,000 live births. Nationally, skilled attendants assist 35% of births. About 17% of women receive any type of postpartum care, including the fortieth day visit. In urban areas, births are more than three times as likely to be attended by a skilled provider than in rural areas. Traditional Birth Attendants (TBAs) attended slightly more than one third of all births nationwide. TBAs attend 30% of births, more than three times as high in Haute Guinea as in other parts of the country. More than 40% of all births are attended by a relative or were unattended. No one at all was with many Guinean women giving birth. In some rural areas, unattended births are as high as 75%.

Many health facilities do not currently provide basic care for obstetric emergencies. For appropriate emergency care, is often necessary to bypass health centers and go directly to a hospital. For 46% of rural women this requires an hour or more of travel by vehicle, if a vehicle is available. The area is sparsely populated with only nine inhabitants per square kilometer, less than half the national population density. This increases the challenge of providing even basic maternity care.

Save the Children staff trained the interviewers. The training reviewed the research objectives, discussed basic concepts of early postpartum care, reviewed the maternal and newborn health terms that would be "translated" into local terms and definitions, and provided an overview of basic interview techniques. Community interviewers reviewed and translated each research instrument into Malinke.

• Many respondents knew several basic obstetric danger signs. However, awareness of the specific danger signs during the early postpartum period needed strengthening, particularly of the most common causes of death during the early postpartum period for women (hemorrhage, sepsis and pregnancy-induced hypertension) and newborns (asphyxia, sepsis and sequelae of low birth weight). Strategies to increase knowledge of danger signs could build on existing awareness of dizziness, bleeding and fever.
• Participants, including skilled attendants and village health committee members, were willing to learn more about pregnancy, birth and postpartum and supplied detailed information on when, where and with whom they commonly meet to discuss birth-related topics.
• There was limited community awareness about the need for early postpartum care, especially for mothers. The research identified a need for a strategy to increase demand for early postpartum care. Beginning with birth preparedness plans that include early postpartum care, the strategy should reinforce early postpartum care for the mother and newborn. The strategy should be promoted to women and TBAs and to relatives, since so many births in Guinea are not attended by TBAs. There is a belief that the husband/partner has a responsibility to provide for the birth-related needs of women and newborns. This belief could reinforce the importance for men about the need for early postpartum care in their household.
• There was already a strong cultural tradition surrounding the postpartum period. Findings emphasized the importance of building on positive beliefs and practices by integrating improved behaviors into a framework of accepted beliefs. For example, the strategy could:
  • Reinforce positive aspects of the special waiting period, such as attention to maternal nutrition and special care and social support for mother;
  • Incorporate specific terms already used by the community into their understanding of "protection" of the new mother and baby to include early postpartum health checks; and
  • Select people who did not conflict with taboos related to the waiting period to perform the routine early postpartum checking visit for all new mothers and newborns.
• Potential conflict existed between a culturally accepted isolation of the mother and newborn and need for vigilance to detect danger signs during the first week. The importance of the timing of early postpartum visits, during the first week when cultural "sanctions" are still in place, must be made clear to household members and the early postpartum visitor/link worker. In-home visits could be promoted as harmonious with existing birth tradition. Findings highlighted the need to stress that early postpartum visitors should visit homes twice before day seven. The seventh day is an important "transition" time, when some of the traditional constraints to maternal mobility can be negotiated. The existing practice of taking healthy newborns for vaccination on the eighth day postpartum could be used to promote the equal importance of checking mothers at the same time. In turn, local terms regarding newborn immunization should be integrated into any discussion about early postpartum careseeking for new mothers.
• The early postpartum care option for routine checks should incorporate people's preferences that mothers remain in their homes during the first week after birth, if possible. Participants noted that early postpartum visitors could enter homes to check mothers without violating that important belief. The research identified the need to reinforce checks should be made if even there are no problems.
• Participants observed that an appropriate family member could take mothers and newborns with danger signs to an early postpartum care station without violating customs.
• Community members preferred trained TBAs as early postpartum visitors. The roles of trained TBAs' roles should be expanded to include routine early postpartum care and danger signs checks for both mothers and newborns. At the same time, the role and responsibilities of other recognized community health workers (village health committee members, health agents, etc.) need to be broadened to include monitoring danger signs in mothers and newborns during the early postpartum period.
• The strategy should promote skilled careseeking for complications whenever feasible, and reinforce the existing belief in seeking care at any time, especially during the early postpartum period. It should emphasize that TBAs (both trained and untrained) are a link to, but not a substitute for, skilled care.

It is important to reinforce the positive characteristics of skilled providers as perceived by women and their families. "Trained" was a very important qualifier used by community members to describe their preferred early postpartum visitor.

Skilled providers and village health committee members also overwhelmingly endorsed the concept and shared guidelines they believed would be necessary for the intervention to succeed. Their specific suggestions should be incorporated in the strategy.

Each category of respondent also offered very useful ideas on how to increase community awareness of the need for EPPV in their communities, and these should be incorporated into the dissemination strategy to the greatest extent possible.

Although many of the findings were similar in urban and rural locations, some clear differences were notable. These responses should be considered when developing the early postpartum visitor intervention and behavior change strategy.

Differences between Urban and Rural Communities

Overall recommendation

• Develop an early postpartum care program that includes suggestions for criteria, roles and activities of early postpartum visitors outlined in this study; particularly the use of trained TBAs as link workers who would work in close association with the village health committee and skilled providers.

Strategy Components

• Develop activities to increase knowledge of danger signs related to pregnancy and childbearing in the community (with focus on early postpartum danger signs).
• Develop activities to increase communication between husbands and their wives during pregnancy, particularly in preparing for childbirth.
• Increase awareness of the community obstetric emergency referral system, particularly the importance of families contributing to the community bank.
• Explore the possibility of expanding the community bank to include normal delivery instead of just complications.

• Involve the opinion leader of the community (Imam, mayor and district president) in the early postpartum care awareness campaigns and sessions.
• Use rural radio as a source of disseminating early postpartum care information.

Training

• Reinforce the training of both skilled providers and trained TBAs in terms of early postpartum care.
• Train more TBAs so that all communities have a least one trained TBA to help women prepare for birth, assist birth and provide postpartum care.

• Ensure that all parties involved respect official tariffs for services and drugs at the health facilities.
• Finalize the contract between the village health committee, community bank and the referral center (hospital).

In Mandiana District, however, respondents expressed a high degree of willingness to change current behaviors and to consider alternative early postpartum care options. Their willingness to change a given practice - early postpartum care - increases the likelihood of rapid, measurable behavior change. Respondents had realistic suggestions about which option would be the most feasible and how to tailor it to local needs, within the constraints that exist for both clients and providers.

The results from Mandiana provide an example of research to support behavior-based programming and community negotiation. The research results can be directly applied to behavior change strategy formulation. Community members began applying the results during community meetings.

Tools (Danger Signs Plus)

Report