Perspective Chapter: Challenges to Postnatal Care in Sub-Saharan Africa – A Review

Abstract

The postnatal period remains the most at-risk period for the mother-infant dyad. Most maternal and neonatal deaths occur in the immediate postnatal period, contributing to the greatest burden of child mortality. Appropriate care for mothers and newborns during this critical period is essential to improve their survival. However, access to quality care during this period remains a challenge, especially in resource-limited settings. This chapter examines challenges to postnatal care (PNC) in sub-Saharan Africa (SSA), drawing on existing evidence. A comprehensive review of critically appraised literature was undertaken. The findings indicate suboptimal uptake of PNC, resulting in high maternal and neonatal morbidity and mortality in the postnatal period. Challenges to the delivery of quality PNC include poor healthcare infrastructure and access to basic health services, and underlying structural determinants such as widespread poverty, illiteracy, harmful cultural practices, marginalization of women, and inadequate political will by governments. These challenges underscore the need for intensified efforts to improve PNC in the region. Innovative approaches to increasing demand and reaching mothers with PNC services within communities are critically needed to improve access and utilization of PNC in SSA, improve maternal and child health outcomes, and contribute to achieving the sustainable development goals in 2030.

1. Introduction

The postnatal period, which starts after birth and lasts for 42 days, is a crucial phase for the health and survival of the mother and the baby [1]. Most newborn fatalities occur within the first month of life, with three-quarters of these deaths occurring within the first 24 hours [2]. In addition, two-thirds of maternal deaths in low- and middle-income countries also occur in the postnatal period [3]. Postnatal care provides opportunities to obtain health interventions and support that are essential for the health and survival of the mother and child. These include interventions such as exclusive breastfeeding, adequate nutrition during nursing, newborn care guidance, and family planning procedures [1].

Sub-Saharan Africa (SSA) has disproportionately high rates of maternal mortality, mostly as a result of inadequate utilization of maternal healthcare throughout pregnancy, childbirth and the postnatal period [4]. Studies have demonstrated the effectiveness of maternal health services including antenatal, childbirth, and postnatal care in preventing maternal and newborn morbidity and mortality. Maternal health services provide important health information for optimal pregnancy outcomes and prompt management of health problems to reduce maternal and newborn morbidity and mortality [1, 4]. Therefore, one of the important measures for eliminating preventable causes of maternal and newborn deaths is increasing coverage of the completion of the maternal and newborn continuum of care, which includes postnatal care [5].

This chapter aims to examine the status of postnatal care in sub-Saharan Africa and the challenges associated with access and utilization by mothers. It also aims to highlight key issues, which might enable governments and stakeholders to develop effective policies and strategies to address these challenges and improve the quality and uptake of postnatal care services towards improved survival and health outcomes. Furthermore, the discussions in this chapter are critical to expanding our understanding of postnatal care in sub-Saharan Africa.

2. Status of maternal and newborn health and survival in sub-Saharan Africa

According to the global sustainable development goals (SDG) targets, by 2030, the maternal mortality ratio should be reduced to less than 70 maternal deaths per 100,000 live births, with no country having more than twice the global rate of 140 maternal deaths per 100,000 live births, and there should be no more than 12 neonatal deaths per 1000 live births, globally [5, 6]. Although progress has been made in reducing mortality rates among mothers and babies, recent evidence suggest stalled progress on preventable maternal deaths, globally [7]. For example, in 2016 alone, 7000 newborn babies died every day. Newborn deaths made up 46 per cent of all child deaths, an increase from 41 per cent in 2000 (Figure 1) [8].

Figure 1.

Based on estimates by the United Nations inter-agency Group for Child Mortality Report, 2020 [8].

Compared to other regions, countries in the SSA region have made the least progress in lowering maternal and neonatal death rates [7, 9]. The sub-region still has the highest maternal death rate, estimated at about 542 per 100,000 live births in 2017 [10]. Since 2000, maternal death rates have decreased by 33% in a number of Sub-Saharan African countries, but the region still accounted for 70% of global maternal mortality in 2020 [11]. Also, despite making up 16% of the global population, 38% of newborn mortality takes place in Africa [8]. Between the period from 1990 to 2017, SSA recorded a 40% reduction in neonatal mortality rates, which was lower than that observed in high-income nations (55%) [12]. Despite progress, the SSA region still has a long way to go to achieve its 2030 target of zero preventable maternal, stillbirth, and neonatal deaths [5]. To achieve the 2030 targets, the region’s average yearly reduction rate would have to be doubled [13]. It is important to critically appraise and understand these trends and institute appropriate measures towards achievement of the SDG targets for 2030.

3. The role of postnatal care in averting maternal and newborn deaths

Postnatal care (PNC) plays a critical role in preventing morbidity and mortality in mothers and babies [1]. In sub-Saharan Africa, the predominant causes of maternal mortality are postpartum hemorrhage, hypertensive disorders and postpartum sepsis, while infections, low birth weight and asphyxia are the main causes of newborn deaths. These infections include those that are common in preterm babies such as sepsis, meningitis, pneumonia and diarrhea, nearly all of which can be prevented or managed with appropriate PNC [1]. If care is provided as soon as the baby is born, most of the neonatal deaths that happen within the first 48 hours of life can be avoided [14, 15]. For instance, interventions such as ensuring a clean and safe delivery, which includes having clean hands, perineum, delivery surface, cord-cutting surface and instruments, proper umbilical cord care in order to minimize infections in mothers and babies, and starting breastfeeding immediately after birth might reduce maternal and neonatal infections and associated mortality significantly [14, 15, 16]. In addition, the WHO PNC recommendations promote immediate and exclusive breastfeeding, examining the mother and baby for danger signs and referring patients appropriately [14]. Early PNC interventions for neonates include kangaroo care, breastfeeding assistance, hypothermia prevention and treatment, as well as case management and referral for pneumonia [1]. For preterm infants, low birth weight babies, infants with HIV-infected mothers, and other high-risk situations such as babies with neonatal jaundice or who have recovered from birth asphyxia, acute surgical problems, genital tract abnormalities, as well as orphaned and abandoned babies, specialized PNC monitoring is also recommended [1]. By providing key assistance that identifies warning signals, promotes beneficial behaviors, and streamlines referral procedures, postnatal care (PNC) plays a critical role in lowering morbidity and mortality rates in mothers and babies [1]. Given that interventions during the postnatal period can prevent a significant proportion of maternal and neonatal deaths, increasing efforts to improve uptake of postnatal care is particularly crucial for lowering maternal and neonatal mortality rates [4, 5].

4. Maternal healthcare utilization in sub-Saharan Africa

Since 2015, there have been considerable improvements in maternal healthcare utilization in sub-Saharan African countries [17]. Yet challenges remain in ensuring universal access and utilization of maternal health services. Differences in care-seeking habits and poor usage of maternal and newborn health services are blamed for sub-Saharan Africa’s slower progress in improving maternal, neonatal and child health outcomes [18]. For instance, just 48% of women in the region deliver their babies with the help of skilled attendants, compared to 72% of women globally [19]. Additionally, SSA nations continue to see persistent disparities in access to, and utilization of high-quality services, with notable access gaps between the poor and non-poor populations [20, 21]. Socioeconomic status and the location of the mother’s residence have a major impact on the use of maternal, neonatal and child healthcare, with persistent wealth-related disparities [9]. The least equitable interventions, according to a study of 54 low- and middle-income countries, were four or more ANC visits and skilled birth attendance coverage. The lowest quintile (32%), in comparison to the richest quintile (84%), had lower mean skilled-birth attendance coverage [22]. This situation has a significant impact on postnatal care utilization.

5. Determinants of maternal and newborn healthcare utilization in sub-Saharan Africa

Several studies have documented various facilitators and barriers to women’s access to healthcare during pregnancy, childbirth and the postnatal period in SSA [23]. These determinants occur at the individual, health system and contextual levels.

5.1 Individual factors

At the individual level, maternal age, educational attainment, occupation, income, religion, family structure, information accessibility, location of residence, health awareness, and decision-making authority are all factors that affect maternal and newborn healthcare access and utilization [24]. For instance, exposure to local media and information sources has a positive impact on maternal and neonatal care utilization [25], and frequent broadcast of the benefits of birthing at a healthcare facility encourage mothers to adopt health facility deliveries [25].

5.2 Health system factors

At the health system level, maternal healthcare utilization in sub-Saharan Africa is influenced by factors that include accessibility to healthcare facilities, perceived quality of care, financial cost, timeliness of care, availability of drugs and equipment, and emergency care [26, 27]. Healthcare quality considerations include human resource availability, the population-to-healthcare-professionals ratio, and service accessibility [28, 29]. Women are more likely to use maternal healthcare services if they reside in areas with high-performing and high-quality health systems. However, some studies have also reported either a negative association between distance and maternal healthcare utilization or no significant association [29, 30]. In these instances, increased rates of facility delivery were attributed to contextual factors such as access to health facilities within communities, which appeared to have an impact on immediate postnatal care [29].

5.3 Contextual factors

Individual and health system-level variables reflect “upstream” contextual variables that are ingrained in larger social systems. For instance, discussions of the impact of women’s autonomy and decision-making power on maternal healthcare frequently take place within the context of prevalent masculine beliefs or local cultural norms [31]. Pregnancy and childbirth have typically offered women in sub-Saharan Africa an opportunity to establish their worth and stake an assertion on social status through childbirth [32]. In cases where a woman gives birth without external support, she is held in high esteem. Such perspectives may influence the decision of childbirth at home without the support of any health professional. Also, in some communities, local beliefs prevent health facility deliveries as they are considered unacceptable [33]. Expectant mothers, out of fear, choose to appease their families by having home births in order not to endanger their lives and that of their babies [33]. These beliefs make it difficult for mothers to freely access maternal health care. In some traditional settings, the consent of the woman’s spouse is often required to access care at a healthcare facility [34]. Some men insist on home birth in order to prevent their wives from being attended to by male health personnel [34]. For women who live in vulnerable environments such as in conflict and war situations, the risk of being kidnapped, raped or killed makes it impractical to travel to a health facility for childbirth and PNC services [35]. Similarly, the dysfunction of the political and governance institutions that control health systems may have a direct or indirect impact on health systems. Contextual-level factors strongly explain variability in individual access to healthcare and health outcomes [36].

6. Postnatal care utilization in sub-Saharan Africa

Data from Demographic and Health Surveys conducted in 23 African nations show that less than 13% of women in sub-Saharan Africa receive postnatal care within two days of childbirth, and only one-third of women give birth in a medical institution [37]. From 2006 to 2018, the pooled magnitude of postnatal care service utilization in sub-Saharan African countries was 52.48% with the highest utilization in the central region of Africa (73.5%) and the lowest utilization in the eastern region (31.7%) [23]. Progress is being made and in many countries, a significant proportion of women increasingly access PNC [5]. However, postnatal care utilization remains low within the continuum of care.

7. Challenges to postnatal care in sub-Sahara Africa

Several challenges to PNC in sub-Saharan Africa have been documented [23].

One of the key challenges associated with postnatal care in SSA is a lack of access to basic healthcare services [23]. Many women in the region live in remote, rural areas that lack adequate healthcare facilities [35, 38]. Healthcare facilities in the region are often understaffed, and the staff available may not be adequately trained to provide the care that is needed [18]. The facilities also lack basic medical supplies such as drugs and equipment, which can make it difficult for healthcare workers to provide the care that is needed, and for women to receive appropriate care during the postnatal period [18, 38].

Even when postnatal care services are available, a variety of sociocultural barriers prevent mothers and their newborns from accessing these services. These include household barriers related to the educational level and health literacy of mothers and other family members, the influence of sociocultural beliefs and practices, and women’s autonomy and decision-making power [39]. Specific examples of sociocultural barriers to postnatal care utilization include cultural beliefs about the 40 days following childbirth, during which mothers and babies should stay indoors [40], misconceptions about the importance of postnatal care, and a lack of knowledge about postnatal care and its benefits [35].

At the individual level, a woman’s education and literacy level, occupation, income and access to information influence her access and utilization of PNC. At the health system level, the cost of health services, transportation, accessibility, travel time and distance to healthcare facilities all influence utilization of PNC. The functionality and standard of health systems at the community level, the standard of care provided at the facility and concerns about the quality of care, including the attitudes of health workers, their skills, resources, workload and effect on the quality of care, and the cultural acceptability of services all influence women’s decision to seek PNC [28, 35].

Socioeconomic characteristics such as place of residence, cultural attitudes, gender norms, women’s autonomy and empowerment, wealth or poverty levels in the community, levels of education at the community level, population density, and the government’s contribution to healthcare spending, and gross national income per capita are contextual variables that affect the utilization of postnatal care [25, 29]. The extent of poverty, socioeconomic development and infrastructure, including poor roads and transportation, can also make it difficult for women to reach healthcare facilities, even if they are available [18, 35, 38].

Utilization of postnatal care is correlated with several of these factors predictably and consistently. For instance, it is well known that women are more likely to use maternal healthcare if they reside in regions or countries with higher socioeconomic or educational standards. it is also well known that women who reside in rural regions are less likely to use postnatal care and other maternal healthcare services. Many women in the region live in poverty and do not have the resources, information, autonomy and decision-making power to access care during the postnatal period. Discrimination and other social factors also make it difficult for women to access and receive the care they need [18, 35, 38].

Contextual factors such as cultural beliefs and practices, also hinder the delivery of quality postnatal care in SSA [18, 35]. Many women in the region follow traditional birthing practices, which can make it difficult for healthcare workers to provide the care that is needed [35]. Additionally, there may be cultural taboos surrounding certain aspects of postnatal care, such as institutional childbirth, which can make it difficult for women to access PNC [33].

One of the strongest predictors of postnatal care use is women’s empowerment and autonomy [41]. The evidence suggests, that living in communities where the majority of women are empowered, that is, educated and financially independent, is advantageous for access and utilization of postnatal care in sub-Saharan Africa [29]. Furthermore, women who reside in places where their freedom is curtailed, due to certain cultural beliefs or social restrictions on women and/or insecure places such as conflict situations are less likely to seek postnatal care after childbirth. Relational factors have also been shown to be significant contextual determinants of postnatal care use. These elements mostly stem from regular contacts or relationships that women have with males. These relationships may have an impact on whether or not women choose to receive maternity care. Furthermore, household size, the number of children per household, and small family norms also influence the decision to access postnatal care [41].

8. Conclusions and recommendations

Postnatal care is beneficial and essential for maternal and newborn survival, yet access and utilization of these services are still low in SSA and vary among nations. This chapter demonstrates how individual, health system and contextual factors influence postnatal care access and utilization in sub-Saharan Africa.

In summary, postnatal care in SSA is confronted with significant challenges, including a lack of access to basic healthcare services, poor infrastructure, inadequate staffing and training, and limited resources. Cultural beliefs and practices as well as socio-economic factors that hinder women’s autonomy and ability to make decisions regarding their health also play a role in hindering access to quality postnatal care. These challenges, coupled with high rates of maternal and infant mortality, underscore the need for targeted interventions and resources to improve postnatal care in the region. Efforts such as empowering women socially and economically, providing education, training healthcare professionals, and building or upgrading healthcare infrastructure can help to address these challenges and improve access, quality and utilization of postnatal care for mothers and babies in sub-Saharan Africa.

The fact that a high proportion of childbirths occur outside of healthcare institutions is one of the biggest obstacles to providing postnatal care in sub-Saharan Africa [37]. To address this challenge, postnatal care services must be made available in a vicinity near the home or at home, especially for women who give birth outside of medical facilities [14]. This is particularly important in communities where access to early postnatal care is restricted by cultural, socioeconomic, and geographic constraints. Currently, WHO and UNICEF, through the “Every Woman and Newborn” Initiative [5] are supporting countries to strengthen their routine health information systems to capture information on “early routine postnatal care utilization” (within 2 days of birth), to facilitate the achievement of the global target of 80% coverage of “early postnatal care” and national target of 90% of countries with >60% coverage [42]. Increasing coverage of skilled birth attendance is also likely to impact uptake of PNC significantly within the SSA region.

To accelerate progress in reaching the SDG global targets, it is essential to promote the completion of the maternal and newborn continuum of care, which includes care during the postnatal period, especially within 2 days after birth, due to the vital role of care during this period in improving the survival of mothers and their babies [5]. It is also essential to attain high-quality postnatal care with equity in all countries. Such efforts are likely to improve health outcomes for women and children and contribute to achieving sustainable development goals (2030).

Acknowledgments

We acknowledge the support of the WHO HRP Alliance (UNDP-UNFPA-WHO-World Bank) Special Programme for Research and Training in Human Reproduction (HRP), a co-sponsored programme executed through the University of Ghana School of Public Health, in the preparation and dissemination of this review.

Conflict of interest

The authors declare no conflict of interest.