Postpartum care needs assessment: women's understanding of postpartum care, practices, barriers, and educational needs.

BACKGROUND: Complications in the postpartum period pose substantial risks to women and can result in significant maternal morbidity and mortality. However, there is much less attention on postpartum care compared to pregnancy and childbirth. The goal of this study was to gather information on women's knowledge of postpartum care and complications, recovery practices after childbirth, perceived barriers to receiving care during the postpartum period, and educational needs in four health centers. The findings can inform the development of appropriate curriculum and interventions for postnatal care education in similar settings. METHODS: A descriptive qualitative study design was employed. Eight focus group discussions were conducted among 54 postpartum women who delivered in four health centers in Sagnarigu District in Tamale, Ghana. Audio recordings of focus group data were transcribed and translated, and thematic analysis was conducted. RESULTS: There were six main themes that emerged from the focus group discussions: 1) baby focused postpartum care; 2) postpartum practices; 3) inadequate knowledge ofpostpartum danger signs; 4) barriers to accessing postpartum care 5) experiences of poor mental health; and 6) need for postpartum education. CONCLUSIONS: Postpartum care for women in this study was primarily perceived as care of the baby post-delivery and missing key information on physical and mental health care for the mother. This can result in poor adjustment postpartum and critically, a lack of knowledge on danger signs for common causes of morbidity and mortality in the postpartum period. Future research needs to understand how to communicate important information on postpartum mental and physical health to better protect mothers in the region.

A descriptive, cross-sectional study of postpartum education: midwives' self-reported knowledge and teaching of postpartum complications in Ghana.

BACKGROUND: Obstetric complications remain the leading causes of maternal deaths. Since it is not always possible to ascertain which women will develop complications and which women will not, all women who have a baby should be educated about warning signs of complications. In this study, we assessed postpartum education provided by midwives, midwives' knowledge to teach patients about complications and their skills to manage postpartum complications. METHODS: Descriptive, cross-sectional study of 245 midwives in four hospitals in Tamale, Ghana, using an electronic questionnaire. Data analyzed in Stata 16 software using descriptive, bivariate, and multivariate statistics. RESULTS: Majority of midwives were female (98%). Mean age of midwives was 32 years. Most midwives spent 6 to 15 min teaching patients on warning signs of complications (61.89%). Mode of discharge education was mostly individual (83.13%). Most midwives reported no reference materials given to patients (66.39%). About 93.45% of midwives strongly agreed or agreed it is their responsibility to teach all patients, regardless of risk factors, about warning signs of complications. However, midwives did not always teach patients about complications. The majority of midwives felt they were knowledgeable or very knowledgeable to teach patients about hemorrhage (95.08%), infection (94.67%), preeclampsia/ eclampsia (90.95%), and hypertension (89.35%). Similarly, most midwives felt they had the skills to manage these same four obstetric complications. Unsurprisingly, most midwives were more likely to always educate their patients about hemorrhage, infection, preeclampsia/ eclampsia, and hypertension-the complications they were more knowledgeable about. Many midwives felt not knowledgeable about and not competent to manage postpartum depression, cardiac events, pulmonary embolism, and venous thrombosis. In the same regard, many midwives did not teach patients about the life-threatening complications they were least knowledgeable about. CONCLUSIONS: Midwives did not always teach patients about complications. Most midwives felt knowledgeable to teach and manage hemorrhage, infection, and preeclampsia/hypertension but not cardiac events, pulmonary embolism, and venous thrombosis. Additional training of midwives on life-threatening complications such as pulmonary embolism and cardiac events is recommended.

Complications after childbirth are the leading causes of maternal deaths. All women who have a baby should be educated about the warning signs of complications. In this study, 245 midwives from four hospitals in Tamale, Ghana, completed questions that assessed the education they provide to patients on potential complications after childbirth, their knowledge to teach patients about complications, and their skills to manage complications after birth. Midwives reported that patients stay in the hospital for a day or less if they delivered vaginally or for 3 or more days if they delivered by cesarean section. About 62% of midwives spent 6 to 15 min teaching patients on warning signs of complications; 82% provided individual teaching during discharge; and 66% did not provide take-home educational materials to patients. About 93% of midwives either strongly agreed or agreed that it is their responsibility to teach all patients about warning signs of complications. Results indicated that midwives did not always teach patients about potential complications that can occur after childbirth. Midwives more frequently taught patients about severe bleeding, infections, and complications of high blood pressure, and least frequently taught patients about heart-related complications, blood clots and depression after birth. Most midwives felt they were knowledgeable to teach and manage severe bleeding (hemorrhage), infection, and complications related to high blood pressure (preeclampsia/eclampsia) but not heart-related complications (cardiac events), blood clots in lungs (pulmonary embolism), blood clots in deep vein, usually in legs (venous thrombosis), and depression after childbirth.

Knowledge of postpartum care and postbirth warning signs among midwives in Ghana.

BACKGROUND: In Ghana, midwives are the primary maternity care practitioners. Their knowledge of postpartum care is critical for preventing and reducing maternal deaths because it affects the quality of care provided to women. In addition, midwives' knowledge of postbirth warning signs is important for early identification and management of complications. This study assessed midwives' knowledge of postpartum care and postbirth warning signs to develop interventions to improve patient care. METHODS: A cross-sectional survey of 246 midwives was conducted in the four main hospitals of Tamale, Ghana. Data were collected using a postpartum care knowledge questionnaire developed by JHPIEGO. Data were analyzed in SAS version 9.4 using descriptive, bivariate, and multivariate statistics. RESULTS: Mean age of midwives was 31.9 years. The percentage of midwives who responded correctly to each postpartum care question ranged from 41.6% to 84.9%. Most midwives were knowledgeable about breastfeeding-however, knowledge about fundus location, postpartum examination, and care during first 2 hours postpartum was low. Hospital was associated with knowledge of postpartum care (P < .001). Only 28.1% of midwives identified all nine warning signs of complications. Most midwives could identify severe bleeding, severe headaches, and high temperature as warning signs-however, knowledge of warning signs of some life-threatening complications such as chest pain, obstructed breathing, and thoughts of hurting oneself was low. More years of experience was associated with better knowledge of postbirth warning signs (P = .03). DISCUSSION: Findings suggest a need for additional training of midwives in how to care for postpartum patients and accurately identify warning signs for life-threatening complications.

Revisiting the Quality of Reporting Randomized Controlled Trials in Nursing Literature.

PURPOSE: To examine and update the literature on the quality of randomized controlled trials (RCTs) as reported in top nursing journals, based on manuscripts' adherence to the CONsolidated Standards of Reporting Trials (CONSORT) guidelines. DESIGN: Descriptive review of adherence of RCT manuscript to CONSORT guidelines. METHODS: Top 40 International Scientific Indexing (ISI) ranked nursing journals that published 20 or more RCTs between 2010 and 2014, were included in the study. Selected articles were randomly assigned to four reviewers who assessed the quality of the articles using the CONSORT checklist. Data were analyzed using descriptive and inferential statistics. FINDINGS: A total of 119 articles were included in the review. The mean CONSORT score significantly differed by journal but did not differ based on year of publication. The least consistently reported items included random allocation, who randomly assigned participants and whether those administering the interventions were blinded to group assignment. CONCLUSIONS: Although progress has been made, there is still room for improvement in the quality of RCT reporting in nursing journals. Special attention must be paid to how adequately studies adhere to the CONSORT prior to publication in nursing journals. CLINICAL RELEVANCE: Evidence from (RCTs) are thought to provide the best evidence for evaluating the impact of treatments and interventions by the U.S. Preventive Services Task Force. Since the evidence may be used for the development of clinical practice guidelines, it is critical that RCTs be designed, conducted, and reported appropriately and precisely.

Husbands' knowledge and attendance at wives' postpartum care among rural farmers.

We examined husbands' knowledge and attendance at their wives' postpartum visit in a sample of rural husband-and-wife farmer dyads in central Malawi. A cross-sectional matched-pairs survey of 70 husband-and-wife farmer dyads, who lived in rural communities in Ntcheu district, and had a live birth in the past year was conducted. Data were collected using an interviewer-administered, structured postpartum questionnaire adapted from WHO Safe Motherhood Needs Assessment Questionnaires. Many husbands did not know about postpartum assessments and education their wives received from health facilities. Percent agreement between dyads' responses was lower on questions referring to assessments than to education. The odds of reporting that the woman received postpartum assessments were greater among husbands than among wives. Fifty-nine percent of husbands did not go with their wives for 1-week postpartum visits. Top three reasons for not attending visits were: at work, out of town, and did not see the need.

Use and Evaluation of Postpartum Care Services in Rural Malawi.

PURPOSE: The purpose of this study was to examine women's evaluation of postpartum care services (postpartum clinical assessments, health education, and midwife kindness) received from midwives prior to discharge in rural health facilities, and to examine husband-and-wife-farmer dyads' reasons for their decisions to return or not return for 1-week postpartum care visits in rural central Malawi. DESIGN: Cross-sectional matched-pairs survey design. METHODS: Participants included a convenience sample of 70 husband-and-wife-farmer dyads living in rural communities who had a live birth in the past year at one of four health facilities in Ntcheu district, central Malawi. Data were collected using an interviewer-administered postpartum care questionnaire from the World Health Organization (WHO) Safe Motherhood Needs Assessment Questionnaires. Data analysis included univariate and multivariate statistics. FINDINGS: Women's evaluation of postpartum care assessments received from midwives in rural health facilities prior to discharge included partial assessments of blood pressure (44%), temperature (41%), abdominal examination (50%), vaginal examination/bleeding (46%), breast examination/soreness (34%), and baby examination (77%). Only 16% of the women received all six of these postpartum clinical assessments prior to discharge, while 11% received none. Women also reported that midwives did not: introduce themselves (50%); ask if patients had questions (44%); explain what they were doing (43%); or explain what to expect after delivery (50%). Despite this, 77% of women felt midwives paid close attention to them and 83% gave an overall positive evaluation (3.5-5 on a scale of 1-5). Numbers of postpartum clinical assessments (p = .09) and overall evaluation (p = .71) did not differ between the four health facilities. The top three reasons for husbands' and wives' decisions to return for 1-week postpartum care visits were: being advised to return for care, wanted the mother to be examined, and wanted the baby to be examined. Participants stated prior negative experiences, or not perceiving a need for care (feels fine), may potentially prevent them from returning for postpartum care visits in a health facility. CONCLUSIONS: Most women reported they received only partial postpartum clinical assessments; thus, it is important for health facilities to address the adequacy of postpartum clinical assessments provided to women by midwives before discharge. Women returned for 1-week postpartum care visits because they were advised to return for care, and also to make sure their babies were examined. However, the principal reason why husbands permitted their wives to return for postpartum care was because they wanted their wives to be examined. CLINICAL RELEVANCE: Midwives need to advise all patients to return for postpartum care visits consistent with WHO or country guidelines, and continue to educate husbands and wives regarding the importance of postpartum care even when the wife feels fine. Refresher in-service trainings on postpartum care are recommended for midwives to encourage them to perform the recommended postpartum clinical assessments.

Improving the Quality of Postpartum Care in Ghana: Protocol for a Parallel Randomized Controlled Trial.

BACKGROUND: Although the postpartum period poses substantial risks and can result in significant maternal morbidity and mortality, postpartum care of the mother receives much less attention in transitional countries. OBJECTIVE: We describe the protocol for a randomized controlled trial to implement and evaluate a postpartum care delivery model titled Focused-PPC (Focused Postpartum Care). METHODS: Focused-PPC is an integrated group postpartum care model that meets the clinical care, education, and support needs of mothers up to 1 year after birth. The Focused-PPC intervention is a parallel randomized controlled trial with a total of 192 postpartum women at 4 health centers in Tamale, Ghana. Participants will be randomized into 1 of 2 trial arms at a 1:1 allocation ratio: (1) the control arm, which receives the standard postnatal care currently delivered in health facilities, or (2) the intervention arm, which receives the Focused-PPC model of care. Women enrolled in the intervention arm will receive postpartum clinical assessments and education for the first 6 weeks and will continue to receive education, measures of vital signs, and peer support for 12 months post partum during child welfare visits. Led by trained midwives, each postpartum group in the intervention arm will meet at 1-2 weeks, 6 weeks, and monthly thereafter for up to 1 year post partum, following the Ghana Health Service postnatal care schedule. RESULTS: The Focused-PPC guide, data collection tools, and audiovisual education materials were successfully developed and translated into the local language. We have enrolled and conducted baseline surveys for 192 women (sample size met) in the Focused-PPC trial who have been randomized into intervention and control arms. We have established a total of 12 Focused-PPC groups in the intervention arm, 3 groups from each site, all of which have sessions underway. CONCLUSIONS: Focused-PPC has the potential to change the postpartum care delivery model in Ghana and other countries in sub-Saharan Africa and beyond. TRIAL REGISTRATION: ClinicalTrials.gov NCT05280951; https://clinicaltrials.gov/study/NCT05280951. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/47519.

Predictors of Postpartum Depression Among Women with Low Incomes in the United States.

PURPOSE: To evaluate the predictors of postpartum depression and to examine the effects of maternal racial identity on postpartum depression among women with low incomes in the United States. STUDY DESIGN AND METHODS: We conducted a secondary data analysis using baseline data from the Baby's First Years study, including postpartum women living below the federal poverty line who were recruited from four diverse communities in the United States. Postpartum depression symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CES-D). Logistic regressions were performed to identify associations between pre-identified postpartum depression risk factors and postpartum depression among participants, followed by predictive margins analyses to elaborate on probability of postpartum depression across different racial identity groups in the sample. RESULTS: The sample included 1,051 postpartum women. Almost one-half of participants identified as Black (45.9%), followed by White (20.7%), American Indian (1.8%), and Asian (1.3%). Prevalence of postpartum depression in the sample was 24%. Financial insecurity and alcohol use were positively associated with postpartum depression, whereas level of education and reported physical health were negatively associated with postpartum depression. Mothers who identified as Black had an 8.3% higher probability of postpartum depression than that of White mothers in the sample. CLINICAL IMPLICATIONS: Nurses working with populations with low income should assess social determinants of health to provide holistic mental health care. Women with low incomes should be referred to resources which account for their financial burden. Racial disparities exist in perinatal care, and birth and postpartum mental health outcomes. It is crucial to address the systemic racism faced by Black mothers experiencing postpartum depression.

Discharge Readiness and Associated Factors Among Postpartum Women in Tamale, Ghana.

Ghana experiences a relatively high maternal mortality ratio, with the majority of maternal deaths occurring in the postpartum period. Discharge readiness is a reliable indicator of maternal health outcomes and involves a postpartum woman's perception of preparedness to leave the hospital following delivery. We measured the discharge readiness of postpartum women in Ghana through an institutional-based cross-sectional study involving 151 participants. Participants completed an interviewer-administered survey, and data analyses included linear regression models. The study sample demonstrated relatively high discharge readiness, with a mean score of 177.57 on a scale from 0.00 to 220.00. Higher gravidity was positively associated with discharge readiness score, while longer length of hospital stay and receiving educational handouts were negatively associated with discharge readiness score. Clinical interventions addressing the factors found to be associated with discharge readiness have significant potential to improve postpartum care and maternal outcomes in Ghana.

Knowledge of Postbirth Warning Signs and Postpartum Education Among Women in Ghana.

OBJECTIVE: To assess the relationship between postpartum education and knowledge of postbirth warning signs among women in Ghana. DESIGN: Cross-sectional survey. SETTING: Tamale West Hospital in Tamale Metropolitan Area, Ghana. PARTICIPANTS: Women (N = 151) who gave birth to healthy newborns and were admitted to the postnatal ward. METHODS: We collected data from surveys distributed in the hospital. The survey included items for sociodemographic characteristics, obstetric history, postpartum education provided, and knowledge of nine common postbirth warning signs. We used descriptive statistics and multivariate logistic regression models to analyze the data. RESULTS: Participants reported knowing an average of 5.2 of 9 (SD = 2.84) postbirth warning signs. Severe bleeding (94.70%, n = 143), fever (82.12%, n = 124), and severe headache (72.19%, n = 109) were the postbirth warning signs most frequently identified by participants. Swelling in the leg (37.09%, n = 56) and thoughts of hurting oneself (33.11%, n = 50) were the postbirth warning signs least frequently identified by participants. Knowledge about postbirth warning signs was positively associated with reports of receiving educational handouts on the postnatal ward (adjusted OR = 4.64, 95% confidence interval [1.27, 17.04]) and reports that four or more postpartum complications were taught before hospital discharge (adjusted OR = 27.97, 95% confidence interval [7.55, 103.57]) compared to zero to three postpartum complications. CONCLUSION: All women need comprehensive discharge education on the warning signs of complications after birth. Promoting knowledge of postbirth warning signs can decrease delays in seeking care and contribute to the reduction of maternal mortality in Ghana.

Knowledge of immediate newborn care and management of complications among midwives in Ghana.

OBJECTIVE: Midwives are instrumental in improving maternal/newborn health outcomes. Since complications after childbirth are leading causes of maternal deaths, midwives' knowledge of how to manage complications and care for the newborn is important. This study assessed midwives' knowledge of immediate newborn care and management of postpartum complications. DESIGN: A cross-sectional descriptive survey design was used. SETTING: Four hospitals that provide inpatient maternity services in Tamale, Ghana. PARTICIPANTS: 245 midwives who worked in the four hospitals. MEASUREMENTS: Data were collected in December 2018 using an electronic survey questionnaire by the Johns Hopkins Program for International Education in Gynecology and Obstetrics, and analyzed using descriptive, bivariate, and multivariate statistics. FINDINGS: About 98% of midwives were female. The mean age of midwives was 31.87 years. The percentage of midwives who responded correctly to questions on newborn care and management of postpartum complications ranged from 29.80% to 89.39%, and 32.17% to 91.43% respectively. Midwives were most knowledgeable about breastfeeding and immediate hemorrhage intervention, and least knowledgeable about cord care, thermal protection, newborn resuscitation, contraindications for vacuum extraction, treating metritis, and performing a cervical repair. Years of experience and age are predictive factors of midwives' knowledge. CONCLUSION/IMPLICATIONS: There remains the opportunity for continuing education on complication management. Additional training of midwives on newborn resuscitation is recommended.

Perceptions of Postpartum Teaching and Knowledge of Warning Signs among Black Mothers.

The postpartum period is the time of highest risk for maternal death. Quality postpartum education is important to minimize risk. We assessed the postpartum education given to Black mothers on post-birth warning signs by conducting a cross-sectional survey of 80 Black women who had given birth in the previous 12 months. Participants completed an electronic questionnaire, and data were analyzed using descriptive and regression models. On average, educational needs were reported by 20 participants as being unmet, 27 as being met, and 30 as being more than met. Only 54.4% of the participants reported receiving education about postpartum warning signs. The percentage of participants able to identify each sign ranged from 11.4% to 35.4%. No participants identified more than five of the nine warning signs, and 25% identified none. Knowledge of post-birth warning signs was significantly associated with the delivery hospital, household income, and education on warning signs before discharge.

Cross-Cultural Adaptation and Validation of the Dagbani Readiness for Hospital Discharge Scale-New Mother.

The Readiness for Hospital Discharge Scale-New Mother (RHDS-NM), originally developed for use in English-speaking populations, is an instrument designed to measure women's perceptions of readiness for hospital discharge after birth. We translated and cross-culturally adapted the RHDS-NM into Dagbani and conducted reliability and validity assessments of the new Dagbani RHDS-NM in the Tamale Metropolitan Area, Ghana. The average scale-level content validity index was excellent at 1.00. The Dagbani RHDS-NM had a Cronbach's α reliability coefficient of .94. Exploratory factor analysis indicated four factors with Cronbach's α reliability coefficients of .958, .915, .899, and .667 that represented the Personal Status, Knowledge, Expected Support, and Coping Ability subscales, respectively. Our findings provide initial evidence to support the reliability and validity of the Dagbani RHDS-NM.

Strategies to promote and sustain baccalaureate students' interest in pursuing a PhD degree in nursing.

PhD-prepared nurses are integral to the delivery of cost-effective, safe, and high-quality care to the increasingly diverse population in the U.S. Nurses with a PhD are needed to develop knowledge that informs and directs nursing care, promote positive health outcomes, and train the next generation of nurses and nurse scientists. Unfortunately, less than 1% of nurses have their PhD in nursing and there is an ongoing shortage of nurses in the U.S. that has not been effectively addressed. The PhD in nursing pipeline needs to be bolstered to address the escalating nursing shortage. This is especially important considering the importance of having an adequate number of well-prepared nurses to address the increasing complexities of health conditions and patient populations in the U.S. This paper presents strategies to promote and sustain interest in PhD in nursing among baccalaureate nursing students and discusses the importance of meaningful engagement in research and engaged faculty mentorship. It is important to incorporate research into undergraduate experiences, promote engaged mentorship during undergraduate level and beyond, and provide a conducive environment for undergraduate students to address their fears, misconceptions, and myths about PhD in nursing.

Integrative Review of Factors That Affect the Use of Postpartum Care Services in Developing Countries.

OBJECTIVE: To identify factors that affect the use of postpartum care services in developing countries. DATA SOURCES: PubMed, CINAHL, Global Health, EMBASE, and grey literature were searched for relevant articles in 2015 and 2016 with no publication date limit imposed. STUDY SELECTION: Thirteen studies met inclusion criteria and were assessed for quality with the use of a checklist developed by Fowkes and Fulton (1991) and a checklist developed by the Critical Appraisal Skills Programme (2017). DATA EXTRACTION: The integrative review framework of Whittemore and Knafl (2005) guided the conduct of the review. DATA SYNTHESIS: Results were synthesized based on the three delays model of Thaddeus and Maine (1994). Factors that negatively affected women's decisions to seek postpartum care (Phase I delays) included lack of women's autonomy, lack of exposure to mass media, no pregnancy/birth/postpartum complications, lack of awareness of postpartum care, negative provider attitude, lower levels of women's and husbands' education, women's and husbands' farming occupations, increasing number of children, and lower level of household income. Perceived easy access to a health care facility was associated with lesser odds of using postpartum care (Phase II delay). Hospitals, public health care facilities, and long queuing at a health care facility were associated with decreased postpartum care use (Phase III delays). CONCLUSION: The most common determinants of how women used postpartum care were complications and the education levels and occupations of the women and their husbands. Further research is needed to identify health facility and accessibility factors that affect postpartum care use to develop effective interventions to improve the use of postpartum care.