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Attention to neglected postnatal period saves lives.

In Swaziland, a country with one of the highest rates of HIV infection in the world, the Ministry of Health and Social Welfare has tried to stem the spread of AIDS by adopting a package of methods proven to prevent mother-to-child transmission of HIV. Known collectively as PMTCT, these efforts include promoting HIV testing, offering advice on breastfeeding, and prescribing prophylactic antiretroviral drugs to HIV-positive pregnant women. Because 97 percent of pregnant Swazi women seek antenatal care at least once, the PMTCT program, which was linked to routine mother and child health care services in 2003, has helped improve the quality of antenatal care offered to pregnant women.

First days after birth pose biggest risk for mothers and babies

Yet despite the success in reaching women before they give birth, policymakers have paid little attention to the critical postnatal period. Both babies and mothers are especially vulnerable during the first few days after birth; worldwide, 75 percent of newborn deaths occur in the first week after birth, with half of these happening within the first 24 hours. More than 60 percent of maternal deaths occur within 48 hours of childbirth, yet in Swaziland women and their babies are typically discharged within 12 hours of delivery. Furthermore, the conventional recommendation for the first postnatal visit is at 4-6 weeks after birth. By that time the most critical period has passed, and many of the maternal and newborn deaths have already taken place.

In a number of southern African countries, concern is growing that HIV is contributing to a higher number of maternal deaths due to postpartum sepsis or infection. Yet, the main threats to mothers are postpartum hemorrhage, sepsis, and eclampsia, all of which remain substantially unaddressed. For babies the main cause of death in the early neonatal period is not related to HIV. Practically all newborn deaths in this period are from asphyxia, sepsis, and complications of premature birth.

Population Council reproductive health research associate Charlotte Warren and a team of researchers from the Central Statistics Office and Swaziland's Ministry of Health (in conjunction with the Elizabeth Glaser Pediatric AIDS Foundation and the Basic Support for Institutionalizing Child Survival project) tested ways to take advantage of the link between PMTCT services and routine maternal and newborn health programs. They assessed the effectiveness of a new package of postnatal care in three hospital maternity units and four public health clinics. The team used interviews to gauge the knowledge and attitudes of mothers and health care providers; they checked hospital and clinic registers to determine how often clients used services; and they measured the skills of providers by observing client-provider interactions.

The baseline assessment identified several gaps in service, which were addressed by strengthening immediate care after birth (within the first six hours after delivery); recommending at least one daily exam during a woman's stay at the facility; and improving care and counseling at discharge, including scheduling a specific appointment for the first postnatal visit. The guidelines recommended that mothers return for a postnatal exam at both one and six weeks to receive improved counseling on maternal health, family planning, essential newborn care, and a review of selected issues related to management of HIV and AIDS.

Early attendance at postnatal clinics jumps

A pre- and post-test design allowed researchers to evaluate the effectiveness of the new postnatal service guidelines. After the introduction of the new package of postnatal care, postpartum women were three times more likely to return for a postnatal visit within one week of delivery. Providers' knowledge of essential newborn care also increased.

The researchers concluded that linking postnatal care with high-quality integrated PMTCT programs results in earlier postnatal visits and improved care for both HIV-positive and HIV-negative mothers and their babies. Further, they reported an increase in the proportion of postpartum women and their partners getting tested for HIV. The number of HIV-positive women and their exposed infants who started cotrimoxazole prophylaxis also increased.

A significant increase was seen in the proportion of mothers who breastfed their babies within one hour of birth among both HIV-positive and HIV-negative women. There was also a significant increase in the proportion of HIV-negative mothers practicing exclusive breastfeeding.

By linking high-quality PMTCT programs with maternal and newborn health programs, policymakers can improve health care for both HIV-positive and HIV-negative mothers and their babies. The package of postnatal care relied heavily on training staff in new ways of organizing and providing services; according to researchers, the biggest obstacle in expanding the project is high staff turnover.


Mazia, G., I. Narayanan, C. Warren, M. Mahdi, P. Chibuye, A. Waligo, P. Mabuza, R. Shongwe, and M. Hainsworth. 2009. "Integrating quality postnatal care into PMTCT in Swaziland," Global Public Health 4 (3): 253-270.

Warren, Charlotte, Rachel Shongwe, Allen Waligo, Mohammed Mahdi, Goldy Mazia, and Indira Narayanan. 2008. "Repositioning postnatal care in a high HIV environment: Swaziland," Horizons Final Report. Washington, DC: Population Council.


Elizabeth Glaser Pediatric AIDS Foundation, US Agency for International Development Basic Support for Institutionalizing Child Survival Project (USAID/BASICS), US President's Emergency Plan for AIDS Relief (PEPFAR)
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Publication:Population Briefs
Geographic Code:6SWAZ
Date:Dec 1, 2009
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