Postnatal and Neonatal...?

Postnatal and neonatal care after home birth: A community-based study in Nepal

Abstract
Background

In Nepal, the majority of women who give birth at home do not visit a health facility for postnatal and neonatal care.
Objectives

This study investigated postnatal and neonatal care practices of women who give birth at home in a central hills district of Nepal.
Design

This study is a part of community-based prospective study in the Kaski district of Nepal. Postnatal and neonatal care practices were collected via structured questionnaires.
Setting

Kaski district of Nepal.
Participants

92 postpartum women who gave birth at home.
Outcome measures

Postnatal care at a health facility and neonatal care practices.
Findings

Approximately 90% (83/92) of women who gave birth at home were assisted by non-skilled birth attendants, and 67% (62/92) received no postnatal care at a health facility within a week post delivery. The main reason for not having postnatal care at a health facility was ‘no perceived need’ (52/62, 83.9%). With regard to neonatal care practices, 67% (62/92) used a delivery kit, 79% (73/92) washed their hands before handling their babies, 70% (64/92) bathed their babies on the second day of birth, while all dried and wrapped their babies with a cloth within half an hour of the birth. However, only 46% (42/92) reported skin-to-skin contact within one hour after birth.
Conclusions

The results suggest that there is great scope to strengthen community-based postnatal and neonatal care to screen for and identify postnatal and neonatal problems, especially at home birth.
Introduction

Neonatal deaths constitute approximately two-thirds of infant deaths in low- and middle-income countries. Three-quarters of all neonatal deaths occur in the first week of life and almost half of all neonatal deaths occur at home.1 In addition globally, 60% of all maternal deaths occur during or soon after birth.2 About 65% of the births in Nepal occur at home3 with the majority of mothers forgoing postnatal and neonatal care until they perceive severe health problems.4 Postpartum haemorrhage is one of the main causes of maternal mortality in Nepal.5 In Nepal, while the maternal mortality ratio and infant mortality rate have reduced since 1996, the neonatal mortality has remained largely unchanged.6 The maternal mortality ratio decreased by 57% from 539 per 100,000 live births in 1996 to 229 per 100,000 live births in 2011. The infant mortality rate decreased by 41% from 79 per 1000 live births to 46 per 1000 live births between 1996 and 2011.7 Increasing access to birthing services at health facilities, as well as women's awareness, family planning and safe abortion might have played a significant role in decreasing the maternal and infant deaths, but does not explain the unchanged neonatal mortality rate.8 However, Nepal's current maternal and infant mortality is still high compared to the average 16 per 100,000 live births in developed countries.9

Neonatal deaths, defined as deaths occurring during the first 28 days of life, decreased by only 34%, from 50 to 33 per 1000 live births between 1996 and 2006, with no further gains recorded in the National Demographic Health Survey of 2011. The stagnant progress since 2006 might be due to inadequate coverage of community-based neonatal programmes, especially for hard-to-reach populations.10 Inequality in reduction of neonatal mortality exists across different socio-economic, ethnic and geographical population groups in Nepal.10 Many of these maternal and neonatal deaths are preventable through access to professional care during and after birth to the mothers and appropriate care to the newborns.11

The direct causes of neonatal mortality worldwide are infections, birth asphyxia, complications of prematurity, and congenital anomalies. The harmful neonatal care practices related to the feeding, hygiene/cord care, thermal control and bathing/skin care can cause infections.12, 13 Use of prelacteal feeds, discarding of colostrum, the use of unsterilised equipment for cord cutting, and bathing immediately after birth are associated with negative health outcomes for the newborns. To address the causes of neonatal mortality, Nepal piloted a Community-Based Neonatal Care Package (CB-NCP) in ten districts in mid-2009, with a plan to cover whole country by 2015.14 The CB-NCP programme consists of seven components that focus on healthy home behaviours for postnatal and newborn care, and are delivered through female community health volunteers and other community-based health workers including maternal and child health workers and village health workers.6 In particular, the CB-NCP programme focuses on identification of neonatal problems (e.g. infections, low birthweight, asphyxia and hypothermia) by providing postnatal home visits on days 1, 3, and 7 after birth.14 Similar community-based interventions in other settings have been shown to be beneficial in improving neonatal care practices to reduce neonatal mortality.15

Neonatal care practices and immediate postnatal care within 24 h of birth for women who give birth at home needs to be considered separately to women who give birth in health facilities who receive professional onsite help for neonatal and postnatal care. This study, part of a larger cohort study, investigated the postnatal care and neonatal care practices of women who gave birth at home. Neonatal and postnatal care practices following home births can play a significant role in the reduction of maternal and neonatal mortality and morbidity, as well as being able to guide community-based neonatal and maternal care interventions.
Section snippets
Study design and participants

Data for this study was drawn from a cohort study conducted in the Kaski district of Nepal between December, 2011 and October, 2012. The study was approved by the Human Research Ethics Committee of Curtin University, Perth, Western Australia (approval number HR 130/2011) and the Ethical Review Board of the Nepal Health Research Council (approval number 88/2011). Characteristics of the study district, study design and sampling of the study participants have been described elsewhere.16, 17

In
Characteristics of women who gave birth at home

Of the total 97 women who gave birth at home, three reported intrapartum stillbirths and two reported early neonatal deaths. Excluding these five women, information was sought from the remaining 92 women regarding their birth attendants, postnatal care at a health facility (within 24 h and one week of birth) and newborn care practices. The average age of the respondents was 23.5 (SD 4.9) years and about half of them were in the age group 20–24 years. The majority (43.5%) were first time mothers
Discussion

The majority of women who gave birth at home in this cohort were assisted by non-SBAs, mainly family members. This finding is consistent with findings of several other studies: 90% unskilled assistance in the central plain district of Nepal 22, 94% unskilled birth at central hills district of Nepal 21, 88% unskilled attendance at home births in Bangladesh24 and 83% of home births by family members in India.25 A qualitative study in Tanzania reported that grandmothers, mothers, sisters and
Conclusion

The majority of newborns born at home were bathed after 6 h, their umbilical cords were cut with new blades, nothing was applied to the cut, and they were wrapped within half an hour of birth. The frequency of these practices compare favourably with previous studies in Nepal. Thermal care practices of placing babies in skin-to-skin contact with their mothers, and hygiene practices of washing hands before handling babies continue to have a low uptake. The majority of women reported receiving no
Competing interests

None declared for all authors.
Acknowledgements

This study is associated with the first author's PhD project supported by Australia Awards Scholarship. The authors are grateful to the assistance provided by staff of the District of Public Health Office of Kaski and the data enumerators. The authors are also grateful to Tania Gavidia for her comments to make this paper read better.