Postnatal care: increasing coverage, equity, and quality
Authors: Emma Sacks, Étienne V Langlois
Journal: The Lancet Global Health (2016)

As the Millennium Development Goals came to a close last year and we entered the new Sustainable Development Goals (SDGs) era, the global health community took stock of accomplishments over the past decades and continuing challenges for the future. Despite impressive reductions in maternal and under-5 mortality rates, neonatal mortality reduction continues to lag behind.1Lawn JE Blencowe H Oza S et al.Every Newborn: progress, priorities, and potential beyond survival.Lancet. 2014; 384: 189-205Summary Full Text Full Text PDF PubMed Scopus (1030) Google Scholar Neonates account for an increasing share of child deaths, now reaching almost half (45%) of the burden of under-5 mortality.1Lawn JE Blencowe H Oza S et al.Every Newborn: progress, priorities, and potential beyond survival.Lancet. 2014; 384: 189-205Summary Full Text Full Text PDF PubMed Scopus (1030) Google Scholar Most maternal and infant deaths occur in first 42 days after childbirth.1Lawn JE Blencowe H Oza S et al.Every Newborn: progress, priorities, and potential beyond survival.Lancet. 2014; 384: 189-205Summary Full Text Full Text PDF PubMed Scopus (1030) Google Scholar, 2Ronsmans C Graham WJ Lancet Maternal Survival Series steering groupMaternal mortality: who, when, where, and why.Lancet. 2006; 368: 1189-1200Summary Full Text Full Text PDF PubMed Scopus (1205) Google Scholar Despite the critical importance of this period for both maternal and child survival,3Tinker A ten Hoope-Bender P Azfar S Bustreo F Bell R A continuum of care to save newborn lives.Lancet. 2005; 365: 822-825Summary Full Text Full Text PDF PubMed Scopus (82) Google Scholar postnatal care consistently has among the lowest coverage of interventions on the continuum of maternal and child care, with a reported median for the Countdown countries at just 28%.4Victora CG Requejo JH Barros AJ et al.Countdown to 2015: a decade of tracking progress for maternal, newborn, and child survival.Lancet. 2015; (published online Oct 22.)http://dx.doi.org/10.1016/S0140-6736(15)00519-XGoogle Scholar To reduce mortality and improve health and survival rates of neonates, both access to and quality of services must be addressed. We are in the midst of a paradigm shift for antenatal and intrapartum care: from focusing mainly on coverage to also considering quality as an essential component of improving health systems, as stated in the WHO vision on quality of care5Tuncalp O Were WM MacLennan C et al.Quality of care for pregnant women and newborns—the WHO vision.BJOG. 2015; 122: 1045-1049Crossref PubMed Scopus (492) Google Scholar and other efforts. For intrapartum care, poor quality at facilities, perceived or actual, is now recognised as an important deterrent to care seeking and use.6Bohren MA Vogel JP Hunter EC et al.The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review.PLoS Med. 2015; 12: e1001847Crossref PubMed Scopus (660) Google Scholar Just as women who felt that their antenatal care was of poor quality will not return for intrapartum care,7Berhan Y Berhan A Antenatal care as a means of increasing birth in the health facility and reducing maternal mortality: a systematic review.Ethiopian J Health Sci. 2014; 24: 93-104Crossref PubMed Scopus (76) Google Scholar families will not bring neonates for postnatal care visits at facilities if they are discouraged by staff or treated poorly at prior visits.8Sacks E Kinney MV Respectful maternal and newborn care: building a common agenda.Reprod Health. 2015; 12: 46Crossref PubMed Scopus (25) Google Scholar Yet discussions on reproductive and obstetric care have to date insufficiently addressed the critical issue of quality of postnatal care services. The SDGs include a specific target on neonatal mortality rate reduction. Nevertheless, this is an indicator of mortality and falls short of measuring the content and quality of care. Efforts to improve postnatal care need to include more sensitive metrics for monitoring progress not only of population coverage, but quality and patient satisfaction as well. What is needed is greater attention on the content of postnatal care itself: for example, which specific interventions are delivered to parturient women and neonates? Are these interventions following state-of-the-art clinical guidelines? Is care provided to the mother—baby dyad integrated, culturally-sensitive, and patient-centred? Is increased service use contributing to improved health outcomes? Quality of care encompasses many complex notions that need to be unpacked, including the possibility of iatrogenesis that can occur when the level of quality is poor or unknown.9Chaturvedi S Randive B Diwan V De Costa A Quality of obstetric referral services in India's JSY cash transfer programme for institutional births: a study from Madhya Pradesh province.PLoS One. 2014; 9: e96773Crossref PubMed Scopus (48) Google Scholar Strengthening health systems is crucial for improving the quality of care for mothers and neonates. To increase the responsiveness of systems and improve quality, it is essential to improve infrastructure and equipment; access to energy, water, and sanitation; and recruitment, training, and retention of health workers. Postnatal care quality needs to be addressed at the facility, household, and community levels.3Tinker A ten Hoope-Bender P Azfar S Bustreo F Bell R A continuum of care to save newborn lives.Lancet. 2005; 365: 822-825Summary Full Text Full Text PDF PubMed Scopus (82) Google Scholar Pregnancy surveillance, health education, promotion of facility use, and limited preventive, diagnostic, and curative treatments can be carried out in households and at community levels.10World Health OrganizationWHO recommendations on postnatal care of the mother and newborn. World Health Organization, Geneva2014Google Scholar Tracking and improving the quality and increasing "effective coverage"—ie, coverage of quality postnatal content11Hodgins S D'Agostino A The quality-coverage gap in antenatal care: toward better measurement of effective coverage.Glob Health Sci Pract. 2014; 2: 173-181Crossref PubMed Scopus (126) Google Scholar—at facility and community levels should thus be one of the priorities for the new global health agenda. Addressing quality also means paying close attention to equity and advancing policies that help reduce disparities between advantaged and more vulnerable people. Poorer, less educated, and rural women have been shown to have lower coverage of postnatal care;12Langlois EV Miszkurka M Zunzunegui MV Ghaffar A Ziegler D Karp I Inequities in postnatal care in low- and middle-income countries: a systematic review and meta-analysis.Bull World Health Organ. 2015; 93: 259-270Crossref PubMed Scopus (91) Google Scholar these are the same disadvantaged groups that experience more discrimination and disrespect in facilities as well.6Bohren MA Vogel JP Hunter EC et al.The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review.PLoS Med. 2015; 12: e1001847Crossref PubMed Scopus (660) Google Scholar Reducing barriers to access, including distance and cost, are imperative. Efforts to mitigate inequities in transport to facilities, such as bus and voucher schemes, have shown effectiveness in improving equity of access.12Langlois EV Miszkurka M Zunzunegui MV Ghaffar A Ziegler D Karp I Inequities in postnatal care in low- and middle-income countries: a systematic review and meta-analysis.Bull World Health Organ. 2015; 93: 259-270Crossref PubMed Scopus (91) Google Scholar Yet more effort and investment is needed in ensuring services for all are accessible and high quality. It took a long time for the global health community to seriously address the quality of the content of antenatal care and intrapartum care, beyond coverage indicators. We need to learn from this experience and ensure that quality and integration of postnatal care for mothers and neonates gets political attention and investment sooner. It is incumbent on us to accelerate the trajectory and talk about content and quality for postnatal care within continuing efforts to increase coverage and equity. The time to unpack the "black box" of postnatal care services delivery is now and greater attention should be provided to quality postnatal care in research, policy, and practice. The Global Strategy for Women's, Children's and Adolescents' Health 2016–2030 aims to help people survive, thrive, and transform; thus, the new era cannot only be about survival, but efforts must be made to improve and transform health systems. Quality needs to be understood and addressed if we are serious about reducing neonatal, maternal, and child mortality; progressing toward universal health coverage; and achieving the SDGs. We thank Özge Tuncalp and Steve Hodgins for their review and feedback on a draft of this piece. We declare no competing interests.