status of postnatal care among mothers giving birth at the two hospitals in hanoi and an effect evaluation of home-based postnatal care model

MINISTRY OF MINISTRY OF HEALTH EDUCATION AND TRAINING NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY PHAM PHUONG LAN STATUS OF POSTNATAL CARE AMONG MOTHERS GIVING BIRTH AT THE TWO H

MINISTRY OF MINISTRY OF HEALTH EDUCATION AND TRAINING

NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY

PHAM PHUONG LAN

STATUS OF POSTNATAL CARE AMONG MOTHERS GIVING BIRTH AT THE TWO HOSPITALS IN HANOI AND AN EFFECT EVALUATION OF HOME-BASED

POSTNATAL CARE MODEL

Specialization: Public Health

This work has been completed at

National Institute of Hygiene and Epidemiology

Supervisors

1 Asso.Prof Vuong Tien Hoa, MD PhD.,

2 Nguyen Thi Thuy Duong, MD PhD.,

Opponent 1: Prof Dao Van Dung, PhD

The Central Department of Propaganda and training

Opponent 2: Ass Prof Luu Thi Hong, PhD

Ministry of Health

Opponent 3: Ass Prof Ngo Van Toan, PhD

Hanoi Medical University

The thesis will be public defensed at Institutional committee in National Institute of Epidemiology and Hygiene at ,

LIST OF PUBLISHED ARTICLES RELATED TO DISERTATION

1 Pham Phuong Lan, Vuong Tien Hoa, Le Anh Tuan, Nguyen Tuan

Hung (2011); “Knowledge, practice and needs of postnatal care

among mothers giving birth at National Hospital of Obstetrics and gynecology and Ba Vi District General Hospital”, Preventive

Health Journal, Volume XXI, Number 7 (125), pp.165-174

2 Pham Phuong Lan, Vuong Tien Hoa, Nguyen Thi Thuy Duong, Le

Anh Tuan (2012), “Effect evaluation of home-based postnatal care

at National Hospital of Obstetrics and Gynecology and Ba Vi District General Hospital”, Preventive Health Journal, Volume

XXII, Number 6 (133), pp.124-132

3 Pham Phuong Lan, Nguyen Thi Thuy Duong, Vuong Tien Hoa

(2013), “Analyse related factors to mother's postnatal care

knowledge and practice at National Hospital for Obstetrics and Gynecology and Bavi Hospital 2011”, Preventive Health Journal ,

Volume XXIII, Number 7(143) Pp 110-116

Hiệu quả can thiệp

Tiêm chủng mở rộng

TCYTTG

World health organisation Tổ chức Y tế thế giới

INTRODUCTION

1 Rationale

Postnatal period is very important period that denotes the physical, emotional changes turning "a woman" into "a mother" This is also a sensitive period for mother's and newborns health According to World Health Organisation, there is about 13% & 4% of maternal mortality and 5% & 15% of newborn mortality occur during the first and the second week after birth Therefore, mother's knowledge on postnatal care become vital that will help them to detect early any abnormal signs of themselves and their babies contributing to a decrease in maternal and newborn morbidity and mortality Promoting postnatal care knowledge among mothers could help them provide good practices of postnatal care While the need of postnatal care among mothers increases, many forms

of postnatal care have been presented of which home-based postnatal care should be a good one to share the burden of care with public health sectors It raises many questions for the new model of home-based postnatal care How effective would it be? What are advantages and constrains to conduct this activity? Would it be accepted at different communities? That are reasons to conduct a research named:

“Status of postnatal care among mothers giving birth at the two hospitals in Hanoi and an effect evaluation of home-based postnatal care model"

The research is aiming at the followings:

1 Describing status of knowledge, practice and needs of postnatal care among mothers giving birth at National Hospital for Obstetrics and Gynecology and Ba Vi District General Hospital in 2011

2 Evaluating effects of home-based postnatal care service on mothers giving birth at the two hospitals

2 Findings of the research

- Scientific contribution: The research has fully described knowledge,

practice and needs of mothers on postnatal care in Hanoi in 2011 The authors also explain related factors to postnatal care with an emphasis on traditional belief that may use effectively for development of postnatal care intervention at community levels

This will be the first research in Vietnam on postnatal care services provided by health workers in 10 days after birth, at different community

of rural and urban

- Application of the research: Model of home-based postnatal care

provided by health workers will increase good knowledge and practice on postnatal care among mothers This intervention should be conducted in different communities including rural and urban area Health facilities

from District level should conduct this kind of service at community

3 Structure of dissertation:

This paper includes 131 pages, divided in 4 chapters that consist of Introduction: 2 pages, Chapter 1- Overview: 27 pages, Chapter2- Subject&Research methods: 19 pages, Chapter 3- Results: 51 pages, Chapter 4- Discussion: 29 pages, Conclusion: 2 pages and Recommendations: 1 page It contains 45 tables, 6 charts, 4 objects and a map The paper presents 113 references that include 44 Vietnamese and

67 English and a full questionnaire

Chapter 1 OVERVIEW

1.1 Overview of postnatal care at community

1.1.2 Physiology of normal postpartum and newborn

At postpartum period, there are some changes in maternal uterus, vulva, and breast Some physiological characters occur such as uterus discharge, breast feeding … Among newborns, breathing, jaundice, and other normal physiological signs should be taken into account

1.1.3.1 Postnatal risks for mothers and newborns

In postnatal period, mothers are at risks of pain, fatigue, insomnia, breast problem, and others problems such as exhausted, baby blue, stress or depression

On nutrition, mothers should attain at least 2750 to 2975 Kcal/day for recovery and breastfeeding However, according to National Nutrition Institute, Vietnamese mothers have attained 76% of this requirement of nutrition Additionally, mothers should attain other supplements such as Iron and Vitamin A

On hygiene and labor, mothers should avoid hard motions for resistance

of hemorrhage, decreasing in breast milk amount, Mothers also should sleep for 8 hours/day Mothers are required to take a rush bathing, cleaning their breast and vulva everyday with warm water that will help

to avoid infection Moreover, mothers should practice effectively contraceptives

Newborn are able to get more health problems such as vomit, dieherea, fever, difficult breathing, jaundice or more serious problems such as pathology jaundice, low temperature, etc,

1.1.4 Contents of postnatal health care

World Health Organisation has launched a guideline of postnatal care since 1998 and more updated version in 2008 In Vietnam, National guidelines on Reproductive Health in 2009 has adopted WHO's guidelines in 2008 on the contents of postnatal care

1.2 Knowledge, Practice of mothers on postnatal care

In the world, knowledge and practice of mothers on postnatal care still limit In some are, postnatal practice are seriously influenced by traditional belief In other areas, mothers may not receive a fully care in postnatal period Few mothers are able to be harassed or seriously affected by domestic violence on their health conditions

In Vietnam, many researches have shown a low level of knowledge and practice on postnatal care, especially for those living in remote or mountainous areas Many mothers in Vietnam have limit knowledge on nutrition, hygiene and labor requirements, and dangerous signs after childbirth, as well as the time for active sexual intercourse

1.3 Home-based postnatal care service

Home-based care service provided by health care workers has been conducted in all countries in North and West Europe, in some Asian countries Home-based postnatal care service can promote mothers' knowledge and practice on postnatal care; increase the rate of newborn having breastfeeding and keeping warm

In Vietnam recently, there are some health facilities have conducted home-based postnatal care services in big cities Price for each postnatal care visit varies from 150.000 VND to 700.000 VND There is no

research on the effect of those services on mothers' knowledge or/and practice on postnatal care

Chapter 2 SUBJECT AND RESEARCH METHODOLOGY

2.1 Research site

- National hospital of Obstetrics and Gynecology (NHOG)

- Ba Vi District General Hospital

- Mothers' home

2.2 Research methodology

There are two research designs that best served for the two research

purposes: a cross-sectional and a quasi-experimental research

2.2.1 Cross-sectional study:

2.2.1.1 Time for data gathering: From February to April/2011

2.2.1.2 Research subjects:

- Mother after childbirth

- Family Representative(s) who take(s) care mothers

- Subject 2: Family representatives (Care taker)

In each area, we chose 10 informants for in-deph interview

p(1-p)

d2n=

2.2.1.4 Data gathering methods

There are two methods of data gathering in this paper: quantitative methods (using checklist and structured questionnaires) and qualitative methods (using guidelines for in-depth interview)

2.2.2 Quasi-experimental study

2.2.2.1.Time of study: from June to September/ 2011

2.2.2.2 Studying subjects: Mothers after childbirth at the two selected

hospitals

- Sdudy group: Mothers after childbirth at the two selected hospitals in

Hanoi in the time of studying who agree to use home-based postnatal care service, live in Hanoi and surrounding areas, and sign to consent

form to be subject of study

- Control study: Mothers after childbirth at the two hospitals in time of

studying, who disagree to use any form of postnatal care service, live in

Hanoi and surrounding areas, and accept to be involved in the study

- Other subject study: Care takers at family, health care workers who

provide services and Health authority at the two hospitals

2 2 2

1 1

1 )

2 / 1 ( 2

1

) (

] ) 1 ( )

1 ( [ )

1 ( 2 [

p p

p p

p p

Z p p Z

n n

−

− +

− +

according to previous study of Lê Thị Vân: 40%, P2: estimated

propotion after intervention: 50 %, p: (p1 + p2)/2, Z1- α /2: accuracy of 95% ), Z1-β: sample power (= 80%) Sample size is calculated to be n1 =

n2 = 468 Taking 10% more, we have n1 = n 2 = 519, Total sample size is: 1038

-Qualitatite study: including 10 mothers, 10 Care takers, 06 health care

workers

2.2.2.4 Intervention overview

- Profile: This intervention is a home-based postnatal care service

provided by health care workers for mothers and newborn during 10 days after hospital discharge, including clinical examination, treatment (if any) and health counselling

- Aim of the intervention: Improving good knowldge and practice on

postnatal care among mothers and early detecting any dangerous signs of

maternal and child healthh in this period

- Time of intervention: 10 days after hospital discharge

- Place of intervention: at mother's house

- Contents of intervention: according to the contents of National

Guidelines on RH 2009

- Price of service : in urban area: from 250.000- 430.000 VND/visit, in

rural area: from 125.000 -215.000 VND/visit

mother attains ≥50%, she will pass the assessment

2.4 Data processing and analysing

- EPIDATA 3.1 was used for data entry SPSS soft ware was used for data analysis Descriptive and frequency analysis, T test, Chi square test,

OR and 95% confidence interval were used The statistical significant level of p ≤ 0.05 was used

- Intervention assessment is used through effeciency index and teh efficiency of intervention

- Qualitative data is attained by using in-depth interview, tape recoding,

full text of transcription

Chapter 3 RESULTS

3.1 1.Descibing status of knowledge, practice and needs of postnatal care among mothers giving birth at National Hospital for Obstetrics and Gynecology and Ba Vi District General Hospital in 2011

3.1.1 Status of postnatal care at community

3.1.1.1 Mothers' profile

In a total of 762 mothers participated in the study, 49% come from rural area, 51% come from urban area Most of them are at the age of under 30 (57,5%), having at least professional high school (71,5% in urban group, 53,5% in rural group) There is a difference between two groups on level of education and carrier More 1/2 of mothers who have total income per month during 1-3 millions VND Average number of

3.1.1.2.Accomodation and postnatal care for mother and newborn

There is a difference of accomodation between the two groups regarding types of housing and source of wate (only 4,6% mothers at urban area using drilling water while 26,2% mother at rural used drilling water, p<0,001) Main care takers for postnatal care at home are mother -in-law (55,2%), biological mothers (52%), husbands (44,3%), home servant (12,3%), and sisters (9,8%) Number of mother who has no support from others is very low 0,5% Source of information of postnatal care that mother attainned are different between two areas Mother from urban area receive information mainly from health care workers (46,5%), and Internet (46,2%) while mothers in rural area receive from their mothers (43,3%) and mother-in-law (42,5%)

3.1.1.3 Health status of mothers and newborns

- Mothers' health:

Only 10-20% mothers are coping with health problems afterbirth Common health problems are bleeding, infection, and breast problems respectively Morbidity rate of mothers in rural area is higher than this of mothers living in urban area More mothers in rural group have emotional problems such as assominia (17,3% among rural group compared with 5,4% among urban area), feeling exhausted (7,7% in rural group compared with 2,2% in urban group) and blame themselves (2,85% in

rural group compared with 0% in urban group)

- Newborns' health: Common health problems among newborn are

juandice 3,5% and orher 6% Newborns in rural group have more health

problems than those in urban group

3.1.2 Mothers' knowledge on postnatal care

3.1.2.1 Postnatal care knowledge in 4 main categories

Hygiene

Labour-Nutrition Family

Planing

Pass False

Figure 3.1 Mothers' knowledge of postnatal care in 4 main categories

According to 4 categories of knowledge that have been used in this study, detecting dangerous sign is highest rate of 38%, then family planning: 33,8%, hygiene -labor: 21,7% and nutrition 13% Most of mothers thought that there is no eligible problem for them and their babies in postnatal period Mothers showed their passive thinking on postnatal health care for themselves and their babies as many other care takers get involved

“…I only wish that "mother circle, baby square" (at good health) I don't care about postnatal care as I receive fully support from my mother and mother-in-law I feel confident …” (BM03PSTƯ)

Passive thinking on postnatal period as a safe one is also common among other family members

“ Oh, we only care about labor time There is a proverb “Being pregnant as at gate of cemetory”…I don’t have any to think of instead of taking rest for my self and taking care of my baby …” (GD07BV)

36,2%

Pass False

Figure 3.2 General knowledge of postnatal care

Mothers' general knowledge of postnatal care is still limit There are only 36,2% of mother has passed the assessment score in this study

3.1.3 Mother's practice of postnatal care

3.1.3.1 PC practice in the 4 categories

Table 3.21 Postnatal care practices on labor and hygiene

by living area

n=389

Rural n=373

Total n=762

Taking bath with warm water 281 72,2 279 74,8 560 73,5

Taking bath as usual 13 3,3 3 0,8 16 2,1

Table 3.22 Nutrition practice in postnatal period by living area

N=389

Rural n=373

Total n=762

Qualitative study found that there is few mothers looked for traditional medicine for their babies’ treatment However, some of them used traditional herds for curing themselves For example, mothers used opium for pain relief at uterus or use hot rice bracket massage on breasts for

more milk

3.1.3.2 Mothers' general practice on postnatal care