Postnatal Care (PNC):

Issues, Challenges and

Possible Solutions

Maternal Health Technical Resource Group Meeting, GOI-MOHFW

12th January , 2017
 Why PNC is important?
• 60-70% maternal, neonatal deaths and still births
• PNC crucial for health and survival of mothers/newborns, as a dyad
• Poor PNC, a missed opportunity to promote healthy behaviors
• Increase in institutional deliveries – an opportune movement..!!!
• Without action, by 2035: 49 million additional neonatal deaths; 52 million still
births; and 5 million maternal deaths (Source: Lawn JE et al, Lancet 2014)

Despite high need, PNC has the lowest coverage of

high impact MCH interventions…...!!!!!

Contd..
 Why PNC is important?
Coverage of High impact MCH interventions across continuum of care
Coverage of MCH interventions

urce:
Source:Victoria
Victoria et al,et
Theal, Lancet
Lancet, 2016 2016.
Coverage of Key PNC related interventions, India:2013-14

Visited by Pri.HW within one week 51.0%

Weighed within 24 hr of birth 68.7%

PNC within 48 hrs of birth 39.3%

PNC within 24 hrs of birth 33.6%

Early initiation of Breast feeding 44.6%

SBA 81.1%

Instituional Delivery 78.7%

 Evolving landscape of PNC in India
• Community & home-based newborn care programs – long history

• Increase in facility deliveries – opportunity for facility based PNC

• Ground for facility care – 17,000 NBCCs; 2,200 NBSUs; 600 SNCUs

• More than half a million ASHAs trained on modules 6&7 – opportunity to provide PNHVs

• Capacity building – SBA, LSAS, EmOC, BEmOC, NSSK; IMNCI; F-IMNCI; FBNC

• Initiatives by GOI - INAP; Dakshata, etc.

 Three Inter-related Phases
• Desk Review
• Secondary data review
Formative
Review • Enablers & Barriers to PNC: Qualitative Survey

• Identification of interventions for improving quality & coverage

• Enrichment of strategy for 'implementability'
Synthesis

• Introduce identified interventions in a district

• Monitor the program
Implementation
Research • Document outcomes of implementation
Formative Review Phase
 Methods
• Desk & Secondary data review: ‘how's of PNC’
• Qualitative exploratory survey: ‘what’s & why’s of PNC’
• Criteria used for state selection:
• High institutional deliveries
• Mature HBNC implementation status

• Geography: Two EAG and one non-EAG state

• States selected: Uttarakhand, Odisha and Karnataka
• Criteria for District Selection:
• Ranking of districts based on composite index
• One best and one poor performing district

• State & Districts: Uttarakhand – U S Nagar & Pouri Gharwal

: Karnataka - Gulbarga, Chama Raj Nagar
 Respondent categories per state
Level In Depth Interview (IDI)
State Mission Director
Maternal Health Nodal Officer
Child Health Nodal Officer
ASHA Coordinator
District (per district) CMO/ RCH Officer
IDIs with
DPM/ District Community Mobiliser health
District hospital (per district) Gynecologist/Pediatrician
functionaries
Labor Room Staff Nurse and RDW &
PNC/ANC Ward Staff Nurse FGDs with
Community Health Centre MOIC ASHA
Labor Room Staff Nurse
Primary Health Centre MOIC
Staff Nurse
Community level ANM
ASHA facilitator
Recently delivered woman
ASHA – Focus Group Discussion
 Analytical framework
PNC services

Theme 1: Pre-discharge PNC Theme 3: Interlinkages: Theme 2: Post-discharge PNC:

(Duration, content & quality of (Between facility & (Number, timing & quality of
care) community) ASHA home visits)
 

Sub-themes:  
 Birth preparedness Sub-themes:
  
Current policies & programs  Current policies & programs
 Programs doing well/not doing well  Programs doing well/not doing well
 Need related determinants  Factors affecting quality of care
 Factors affecting quality of care  Characteristics of ASHA
 Characteristics of facility/staff  Logistics, supplies and supportive supervision
 Characteristics of women, family & community  Characteristics of women, family & community
 Post discharge facility PNC/referral from home

Sub-themes:
 Communication between ASHA & staff nurse
 Role of VHND/ANM in PNC
 Linkages of ASHA with district hospital/CHC/ NBSU/SNCU
 Linkages of ASHA with referral transport

Cross-cutting themes:
 Use of HMIS/MCTS data for decision making
 Role of monthly/quarterly meetings for motivating community health workers
 Pre-Discharge PNC at facility
Enablers
• Institutional delivery has become a societal
norm
• JSY payment/birth certificate prolong
duration of stay
• Mother is the primary focus in the labour
room
• Dist Hosp. and some CHCs are able to
ensure 48 hr stay
• Dist Hosp and some CHCs have essential
infrastructure
• State initiatives: mapping of equipment,
‘BPL/SC/ST incentive Scheme-prasooti
araike scheme’, ‘PPP-taayi bhagya scheme’
‘taayo bhagya plus’ etc.
Barriers
• Due to lack of awareness on clear guidelines,
assessment of mother/NB mostly ‘ad-hoc’
• 48 hours not practical – Low/High load facilities
• Quality not ensured - lack of infrastructure/HR/
competing priorities/load
• Lack of confidence to handle sick
mothers/newborns
• Family's ‘no perceived need to stay’ &
opportunity costs
• Discharge slip issued mechanically & no
counselling
• JSSK utilization not optimal
 Verbatim – Pre-discharge facility care
“If MOIC is present in the facility, chances of mother staying till discharge are more as family
gets JSY money and birth certificate which is required to be attached by ASHA with JSY/HBNC
form” (Staff nurse)

“Hamare paas sirf 5 beds hain. Isiliye 48 ghante tak nahi rakhte hain. Kum se kum 24 ghante
rokte hain agar complication nahi hote to.” (CHC Doctor)
 
“It is more than a year since I have used Ambu-bag, I am not confident now on how to use it. I
Know what is ‘pre-eclampsia’, but unable to practice the knowledge as there are no cases”. 
(Staff nurse)
 
“For specialist positions I had to advertise four times without much result at the end. In the
district there is shortage of MOIC and paramedic staff.” (District official)
 
 Post-discharge Home based Care
Enablers
• ASHAs emerging backbone of public
health
• Most ASHAs trained & have basic
knowledge of HBNC
• Newborn is the primary focus at home
• Mostly, established systems in place for
incentive payment
• State policies: ‘Madilu kit’, Skills lab,
ASHA-soft, whatsapp use, ASHA-nidhi,
etc.
• Satellite training, dairy etc.
• Rs 500 (250+250) for PNHVs
Barriers
• PNC not a priority, especially for ANMs
• Fewer visits and not as per schedule
• Poor Quality: short visit, counseling not
proper, physical examination mostly
absent
• Faulty equipment not repaired or
replaced
• HBNC format not in use
• Supportive supervision missing
• Danger signs not identified on time &
referred
 Verbatim – Post discharge homebased care
“ASHAs have better skills and due to their skills now ASHAs have replaced ANM by 60% of their work
in the community”– State Official
 
“Nai dulhan jab gaaon mein aati hai, to kuchh din mein hi, hamari ek dum saheli ban jaati hai woh. Jo
saas se nahi pooch sakti who hum se poochhti hai.”- ASHA
 
“ASHAs are visiting homes and enquiring about the wellbeing. Need to be sensitized about weighing,
temperature measurement and following the structure of home visits”  - State official
 
“Immunization aur deliveries karwana ASHA ke zaroori kaam hai ”  - ANM.
 
“Wazan tolne waali thaili hai spring waali, Thermometer hota hai. Thermometer kharaab ho rakha
hai. Beep ki awaaz bhi nahi de raha hai. Digital ghari hai jo pehle se hi kharaab hui pari hai. Sirf ek
wazan tolne wali thaili, warm pack aur kambal- ye hai ashaon ke paas. Thaili se tolne mein dar lagta
hai….” –ASHAs
 
“Ghar ki bade bol rahe the ki jyada khaana mat, nahi to pait mein dard ho jaayega. Par Asha didi ne
bola masale wala nahi khana par pait bhar ke kha lena.” (RDW)
 Interlinkages between facility and home

Enablers Barriers
• 104 calling center • Ineffective linkages between Facility and
• ASHA-ANM-AWW coordination family/ASHA - Discharge slip issued mechanically
• Inadequate communication between SN and ASHA
through VHND
• PNC is not a priority during VHND
• Limited linkages of ASHA - SN/MOIC • No use of data for monitoring
• ASHA’s mainly coordinating 108

“Our ASHAs are communicating with us and we are in regular touch with them for conducting VHNDs” (ANM
about her communication with ASHA)

“Not all ASHAs have staff nurse number for enquiring about high risk cases management. They mostly call 108
for referring high risk cases to CHC” (Staff nurse)

“No data on PD-PNC monitored at district level. Only institutional deliveries and proportion of
mothers/newborn who received PNC within 48 hours is monitored” - DPM
Implementation phase
 Objectives of Implementation phase
Primary Objective:
To improve coverage and quality of essential PNC services focussing more on pre
discharge care and linkages between facility and community.

Secondary Objectives:
1. To ensure minimum 24 hrs stay for all and 48 hrs for high risk
2. To improve coverage, quality of home visits, including referral
3. Strengthening linkages between facility and community

State: Odisha
 Proposed interventions
Pre discharge Care
• Disseminate and ensure use of available
standard PNC guidelines within facilities
• Stratification of high risk mothers and
newborn in facilities
• Model PNC ward
• Opening communication channels between
ASHA and SN through existing platforms
• IEC/BCC- using existing or new Job Aids, as
required
Post Discharge Care
• Prioritizing PNC: at various forums like
monthly meetings at district, block and
facility level
• M-health: Mobile alerts for ASHA and
family at the time of discharge and regular
home visits
• VHND platform to be strengthened to talk
about birth preparedness and Post natal care

Cross cutting: Use of data for decision making

Monthly Analysis of real time data: m health
Quarterly Analysis of HMIS/ MCTS data
 Improved quality & coverage of PNC
PROVISION OF CARE EXPERIENCE OF CARE
Evidence based care: Guidelines & Risk Effective Communication: maan-ki-baat,
stratification at birth monthly meetings

Actionable Information system: Risk Respect & Dignity: By SNs & ANMs
Proces

specific follow-up with ASHA and all with family

s

Functional referral: Link facility/ASHA Emotional support: Model PNC ward,

with NBSU/SNCU Involvement of ANM/VHND

Competent & motivated HR: Using ‘dakshta’ and monthly meeting and mobile app

Essential physical resources: HBNC forms, equipment & supplies, referral slips, dairy; job aids

Individual and facility level outcomes

Outcome

Coverage of key practices: Facility survey and People centered outcomes: Client satisfaction
medical audits survey at facility and at home

Health Outcomes: Changes in coverage and quality of facility and HNBC

services using baseline/end-line
 Monitoring & Evaluation
• Not to measure impact on mortality or morbidities.
• Measuring influence of interventions (together) on: duration of stay in facility,
satisfaction with services, number of PNC visits, schedule, referral, etc.
• Risk stratification ‘only’ for ensuring appropriate care of high risk mothers/newborns.
Monitoring:
• Monthly project HMIS based monitoring system
• Quarterly analysis of HMIS and MCTS data

Outcomes based on baseline and end-line at facility and at home:

• Lots Quality Assurance Sampling (LQAS) survey of RDW
• Rapid facility & staff survey
THANK YOU