Key factors associated with quality of postnatal care: a pooled analysis of 23 countries

Abstract

Background: Progress in reducing maternal and neonatal mortality, particularly in low-income and middle-income countries (LMICs) and regions, is insufficient to achieve the Sustainable Developmental Goals by 2030. High-quality postnatal care (PNC) for mothers and neonates is crucial for mothers and babies, yet it remains the most neglected intervention on the continuum of maternal and child care. We aimed to estimate the associations between observable factors and high-quality maternal and neonatal PNC in pooled and country-specific analyses.

Methods: In this cross-sectional study, we used the most recent (2015-2022) Demographic and Health Surveys from 23 countries across Africa (n = 14), Southeast Asia (n = 3), Eastern Mediterranean (n = 2), Europe (n = 2), Americas (n = 1), and Western Pacific (n = 1). Women who, within the last 5 years, were aged 15-49 years at their last live birth that had delivered a singleton child were included. We identified eleven PNC behaviours recommended by the World Health Organization (WHO) to measure PNC quality, and applied thresholds to create binary outcomes for quality maternal and neonatal PNC. 15 factors were included in our analysis to assess their association with high-quality PNC for mothers and neonates in a series of single-adjusted and mutually adjusted logistic regression models, both in pooled and country-specific analysis. We also conducted two sets of subgroup analyses for place of residence and maternal age at last birth, and two sets of supplementary analyses to test the robustness of the results.

Findings: Among 172,526 women and their most recent child, 41.42% (40.93-41.91) received quality maternal PNC while 42.34% (41.86-42.83) received quality neonatal PNC. In the pooled analysis, we found that the factors showing the strongest associations with quality maternal PNC were delivery by skilled birth attendants (SBAs) (OR: 4.92; 95% CI: 4.32-5.59), four or more antenatal care (ANC) visits (OR: 1.69, 1.58-1.81), and institutional delivery (OR: 1.61; 1.46-1.78). Consistent results were found for all factors of quality newborn care (e.g., delivery by SBA: OR, 4.25; 3.75-4.81; four or more ANC visits: OR, 1.83; 1.70-1.96) except institutional delivery. The association between these leading factors and PNC quality were broadly consistent across countries. Subgroup analyses and sensitivity analyses showed generally consistent results.

Interpretation: Our study demonstrated that institutional delivery and frequent ANC visits had the strongest positive associations with quality PNC for both mothers and neonates. Our findings highlight that improvements to the quality of maternal and neonatal PNC in the LMICs we assessed are urgently needed to achieve ambitious maternal, newborn, and child health goals.

Funding: China National Natural Science Foundation.

Keywords: Key factors; Maternal and neonate health; Postnatal care; Quality of care.

Fig. 1

Coverage of quality maternal PNC, neonatal PNC, and three essential services in 23 countries. Note: Year stands for the survey year of the data included in the research; PNC indicates postnatal care; ANC indicates antenatal care; SBA indicates skilled birth attendant.

Fig. 2

Flow diagram showing exclusions and final sample sizes of the study population, using the most recent pooled Demographic Health Survey data since 2015.

Fig. 3

Coverage of 11 selected PNC behaviours among women aged 15–49 years, using the most recent Demographic Health Surveys pooled across 23 countries (%). Note: Received maternal PNC timely indicates that the mother received maternal PNC in the first two days after delivery; Received neonatal PNC timely indicates that the neonate received neonatal PNC in the first two days after birth; Examine neonate's cord timely indicates that examination of the neonate's cord occurred in the first two days after birth; Examine neonate's temperature timely indicates that examination of the neonate's temperature occurred in the first two days after birth; Counsel on neonate dangers by health provider timely indicates that the mother received health provider counselling on neonate dangers in first two days after the last birth; Counsel on breastfeeding by health provider timely indicates that the mother received health provider counselling on breastfeeding in first two days after the last birth; Observe breastfeeding by health provider timely indicates that a health provider observed the mother breastfeeding in first two days after the last birth; PNC indicates postnatal care; SBA indicates skilled birth attendant.

Fig. 4

Relative ranking of 15 factors associated with quality PNC from fully adjusted models on maternal care and neonatal care. Note: High maternal education indicates the woman received secondary education or above; High education level of household head indicates the head of the woman's household received secondary education or above; PNC indicates postnatal care; ANC indicates antenatal care; SBA indicates skilled birth attendant; OR indicates odds ratio.

Fig. 5

Country-specific ranking of 15 factors associated with quality PNC from fully adjusted models on maternal care and neonatal care in 23 countries. Note: High maternal education indicates the woman received secondary education or above; High education level of household head indicates the head of the woman's household received secondary education or above; PNC indicates postnatal care; ANC indicates antenatal care; SBA indicates skilled birth attendant; OR indicates odds ratio.

Appendix Fig. S1

Relative ranking of 15 factors associated with quality PNC from supplementary analysis of single-adjusted models on maternal care and neonatal care. Note: High maternal education indicates the woman received secondary education or above; High education level of household head indicates the head of the woman’s household received secondary education or above; PNC indicates postnatal care; ANC indicates antenatal care; SBA indicates skilled birth attendant; OR indicates odds ratio.

Appendix Fig. S2

Country-specific odds ratios for 15 factors associated with quality PNC from fully adjusted models on maternal care and neonatal care in 23 countries. Note: High maternal education indicates the woman received secondary education or above; High education level of household head indicates the head of the woman’s household received secondary education or above; PNC indicates postnatal care; ANC indicates antenatal care; SBA indicates skilled birth attendant; OR indicates odds ratio.

Appendix Fig. S3

Relative ranking of factors associated with maternal PNC from supplementary analysis of fully adjusted models, stratified by place of residence. Note: High maternal education indicates the woman received secondary education or above; High education level of household head indicates the head of the woman’s household received secondary education or above; PNC indicates postnatal care; ANC indicates antenatal care; SBA indicates skilled birth attendant; OR indicates odds ratio.

Appendix Fig. S4

Relative ranking of factors associated with neonatal PNC from supplementary analysis of fully adjusted models, stratified by place of residence. Note: High maternal education indicates the woman received secondary education or above; High education level of household head indicates the head of the woman’s household received secondary education or above; PNC indicates postnatal care; ANC indicates antenatal care; SBA indicates skilled birth attendant; OR indicates odds ratio.

Appendix Fig. S5

Relative ranking of factors associated with maternal PNC from supplementary analysis of fully adjusted models, stratified by maternal age at last birth. Note: High maternal education indicates the woman received secondary education or above; High education level of household head indicates the head of the woman’s household received secondary education or above; PNC indicates postnatal care; ANC indicates antenatal care; SBA indicates skilled birth attendant; OR indicates odds ratio.

Appendix Fig. S6

Relative ranking of factors associated with neonatal PNC from supplementary analysis of fully adjusted models, stratified by maternal age at last birth. Note: High maternal education indicates the woman received secondary education or above; High education level of household head indicates the head of the woman’s household received secondary education or above; PNC indicates postnatal care; ANC indicates antenatal care; SBA indicates skilled birth attendant; OR indicates odds ratio.

Appendix Fig. S7

Relative ranking of 15 factors associated with quality PNC from supplementary analysis of fully adjusted models on maternal care and neonatal care, re-scored by number of PNC behaviours. Note: 1. Maternal PNC behaviours adopted in the construction of PNC include received maternal PNC by a SBA, received maternal PNC in first two days after the last birth, health provider counselling on neonate dangers in first two days after the last birth, and health provider counselling on breastfeeding in first two days after the last birth; 2. Neonatal PNC behaviours adopted in the construction of PNC quality include SBA at neonatal postnatal care, received neonatal PNC in first two days after the last birth, placement of the neonate put on the mother's bare skin after birth, examination of the neonate's cord by a health provider in first two days after the last birth, examination of the neonate's temperature by a health provider in first two days after the last birth, health provider counselling for the mother on neonate dangers in first two days after the last birth, health provider counselling for the mother on breastfeeding in the first two days after delivery, health provider observation of the mother breastfeeding in the first two days after delivery, and weighing of the neonate at birth; 3. Postnatal care quality was calculated using each cut-off value which requires three fourths of total maternal PNC and six ninths of total neonate PNC, accounting for the estimated coefficients from the mutually adjusted model; High maternal education indicates the woman received secondary education or above; High education level of household head indicates the head of the woman’s household received secondary education or above; PNC indicates postnatal care; ANC indicates antenatal care; SBA indicates skilled birth attendant; OR indicates odds ratio.

Appendix Fig. S8

Relative ranking of 14 factors associated with quality PNC from supplementary analysis of fully adjusted models on maternal care and neonatal care, excluding delivery by SBA. Note: High maternal education indicates the woman received secondary education or above; High education level of household head indicates the head of the woman’s household received secondary education or above; PNC indicates postnatal care; ANC indicates antenatal care; SBA indicates skilled birth attendant; OR indicates odds ratio.

Appendix Fig. S9

Country-specific ranking of 14 factors associated with quality PNC from supplementary analysis of fully adjusted models on maternal care and neonatal care in 23 Countries, excluding delivery by SBA. Note: High maternal education indicates the woman received secondary education or above; High education level of household head indicates the head of the woman’s household received secondary education or above; PNC indicates postnatal care; ANC indicates antenatal care; SBA indicates skilled birth attendant; OR indicates odds ratio.

Appendix Fig. S10

Relative ranking of 14 factors associated with quality PNC from supplementary analysis of fully adjusted models on maternal care and neonatal care, excluding institutional delivery. Note: High maternal education indicates the woman received secondary education or above; High education level of household head indicates the head of the woman’s household received secondary education or above; PNC indicates postnatal care; ANC indicates antenatal care; SBA indicates skilled birth attendant; OR indicates odds ratio.

Appendix Fig. S11

Country-specific ranking of 14 factors associated with quality PNC from supplementary analysis of fully adjusted models on maternal care and neonatal care in 23 Countries, excluding institutional delivery. Note: High maternal education indicates the woman received secondary education or above; High education level of household head indicates the head of the woman’s household received secondary education or above; PNC indicates postnatal care; ANC indicates antenatal care; SBA indicates skilled birth attendant; OR indicates odds ratio.