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WHO Technical Consultation on Postpartum and Postnatal Care. Geneva: World Health Organization; 2010.

6.1. Objectives

The objectives of the technical consultation were:

• To identify key topics for development and/or update of the recommendations for care for mother and baby in the postpartum and postnatal periods;
• To prioritize topics for which available evidence should be reviewed.

More specifically, the technical consultation was planned to address the following questions:

• What postnatal services currently are being offered?
• What are the best practices that can be recommended for postnatal care, based on existing knowledge, to promote the optimal health of the mother and newborn infant dyad and their families?
• In addition to strictly biomedical criteria, what characteristics of the individual woman or baby should be considered to select an appropriate approach to care?
• What approaches seem most promising (in terms of effectiveness and cost, for example)?
• What care is needed after discharge to meet the woman's and the baby's physical and psychosocial needs?
• What are the unmet needs of women and newborn babies after home birth without a skilled attendant?
• How should adherence to standards/guidelines be monitored?
• What modifications could and should be made in existing data systems to permit continuous monitoring of postnatal care in both public and private systems, including, for example, electronic medical records, programme information, vital registration, health surveys?

6.2. Participants and proceedings

Participants in the consultation are listed in Annex 1. They included members of the panel of invited technical experts, representatives of UN agencies, observers and WHO secretariat. Participants in the Technical Consultation represented a wide range of clinical, programmatic and research expertise from the different WHO regions.

All presentations and most discussions were in plenary sessions (see Annex 2 for agenda). In addition to prior submission of the formal, signed declarations of interests, all participants were asked to declare any conflict of interest related to the issues to be discussed. None of the participants had any conflict of interest to declare. In addition to the background document provided in advance, participants received during the meeting copies of the two key WHO publications on postpartum and postnatal care (12,13).

The meeting participants discussed the information from the reviews. The task of this panel was not to provide final recommendations but rather to guide WHO secretariat's processes for completing the review. The panel made all decisions by consensus.

The four questions and their sub-questions on care pathways (seeSection 5.2.2) helped the panel to focus on identifying areas in current WHO guidelines that need revision. The panel agreed that the four questions have practical value to implementation: Answers to questions 1 and 3 are of key importance for policy decisions, particularly in relation to the timing of the provision of care. Answers to questions 2 and 4 will give programme managers sufficient technical details on the content of the care package.Section 6.4, below, summarize the discussions and recommendations and supporting evidence addressing the four questions The panel also agreed on the definitions to be used in the guidelines (seenext section).

6.3. Defining terms

The terms “postpartum period” and “postnatal period” are often used interchangeably but sometimes separately, when “postpartum” refers to issues pertaining to the mother and “postnatal” refers to those concerning the baby. The terms “antenatal”, “antepartum”, “intranatal” and “intrapartum” refer to issues pertaining to events before or during childbirth.

For care after childbirth, the panel agreed that adopting just a single term would aid clarity. Therefore, the panel agreed that the term“postnatal” should be used for all issues pertaining to the mother and the baby after birth. Thepostnatal period begins immediately after the birth of the baby and extends up to six weeks (42 days) after birth. For the purposes of describing care provision, the postnatal period consists of immediate, early and late periods (see following paragraphs). Management of the third stage of labour was considered part of care during labour and hence excluded from the discussions. Also, while physiological changes that occur during pregnancy and childbirth may take longer than six weeks to return to the non-pregnant state, the guidance documents will cover only the first six weeks (42 days) after birth. Usually, the end of this period is associated with the implementation of interventions such as promotion of contraception and infant immunization, although some contraceptive methods, such as the lactational amenorrhoea method, the IUD, vasectomy and female sterilization, should be discussed even before childbirth, and some immunizations, such as those against hepatitis B and tuberculosis (BCG), may be given at birth.

Theimmediate postnatal period refers to the time just after childbirth, during which the infant's physiology adapts and the risks to the mother of postpartum haemorrhage and other significant morbidity are highest. The immediate postnatal period covers the first 24 hours from birth. Close direct or indirect supervision by a skilled attendant is required in this period so that any problems can be identified promptly and appropriate intervention or referral can take place.

Some problems—for example, with infant feeding or infection—may first manifest themselves during the first week after birth (that is, after Day 1, the immediate postnatal period). In order to better organize care, the time frame for the period after the first 24 hours is described in terms of days. While there can be a 23-hour discrepancy in the description of “a day”, this framework appears to be generally used and understood. Therefore, the panel agreed to refer to the period from Days 2 through 7 as theearly postnatal period and the period from Days 8 through 42 as thelate postnatal period.

Definitions of other terms appear in theGlossary (see Annex 3).

6.4. Assessment of existing guidelines and information on the postnatal period

6.4.1. Epidemiological considerations in the postnatal period

Large numbers of women and newborn babies have no access to health care immediately following birth. Hence, their risks of ill health and death are high. Demographic and Health Surveys (DHS) conducted in 30 developing countries in five regions between 1999 and 2004 reported that a country average of nearly 40% of all women with a live birth in the five years before the survey did not receive any postpartum care check-ups (23). Among the women who gave birth outside facilities, on average just over 70% received no postpartum care. Among all women who did receive postnatal care, health professionals reportedly provided 57% of postnatal care. The remainder received postnatal care from traditional birth attendants (TBA) (36%) and others (7%).

Some 50% of maternal deaths and 40% of neonatal deaths occur within 24 hours after childbirth (4). The risks decrease after the first few hours but do not vanish entirely. Some problems may arise during the early postnatal period and, less often, in the late postnatal period. Recognizing the clustering of adverse events and risks (seeFigures 1–3) helps in selecting the optimal times to provide postnatal care.

Figure 1

Obstetric and neonatal epidemiology: timing of onset of condition or provision of care. * HurtLSRonsmansCTime since pregnancy and mortality in women of reproductive age in Matlab, BangladeshPresented at the British Society for Population StudiesDecember(more...)

Figure 2

Proportion of maternal death by days postpartum. Source (Figure 2): BaquiAHRates, timing and causes of neonatal deaths in rural India: implications for neonatal health programmesBulletin of the World Health OrganizationSeptember200684970671317128340.(more...)

Figure 3

Proportion of neonatal deaths by day. Source (Figure 3): BaquiAHRates, timing and causes of neonatal deaths in rural India: implications for neonatal health programmesBulletin of the World Health OrganizationSeptember200684970671317128340.

Figure 1 presents information on the frequency and severity of conditions for the mother and infant by day for the first week and then by week. Although data on the incidence and severity of these medical conditions in developing countries are scarce, the panel noted that the information provided in this figure was useful to the discussions on optimal timing of contacts and the contents of care. The panel recommended identifying mortality data from different settings to strengthen the information base relevant to the length of stay and timing of contacts.Figure 1 also shows the optimum period for delivering preventive measures.

Some 3% to 4% of women have lost their babies in the first days after delivery (4). It is important to increase awareness that these women need postnatal care as much as women with infants.

6.5. Conclusions

The panel concluded that the guidelines should consider the needs of the mother-infant dyad. Any recommendation should place the woman and her newborn at the center of health provision and allow women to make informed choices about their own care and their babies'. The panel agreed that the woman and her partner/family require more information than they usually receive on care of the baby and mother within the first week after childbirth.

As for the timing of contacts after discharge, support for exclusive breast feeding (EBF) at the end of the first week, when feeding difficulties most often occur, can prolong EBF. Hence, a visit at this time would be appropriate. Still, the experiences and expectations of women and their families should be considered when deciding the timing of postnatal visits. Barriers to the uptake of services and/or access to services also should be considered when deciding on schedules for postnatal care.

The availability of effective community support after discharge from a facility also is important. The competencies required in the community for postnatal support that improves outcomes should be studied. The formal health sector is responsible for continuing care in the postnatal period after discharge from facilities, but communities can help. Evidence should be evaluated on the effectiveness of current models of collaboration between health services and communities that appear to be transferable to low-resource settings.

The panel noted that additional information is required to make recommendations on the timing and frequency of postnatal visits. To obtain more information, the panel recommended identification and review of non-English language guidelines as well as review of information and evidence on the following: :

• women's expectations and experiences with care in the postnatal period;
• current practice and best evidence on the timing and number of postnatal visits;
• existing models of collaboration for postnatal care among heath care providers and among levels of care, including the family and the community;
• the closure of the postnatal period for the mother and baby;
• the effect of the competencies of the giver of postnatal care on maternal and infant health outcomes;
• the roles of different types of care providers in reducing maternal and neonatal morbidity and mortality;
• the cost-effectiveness of different types of community support in reducing maternal and neonatal morbidity and mortality;

The panel expressed concerns about the limited amount of evidence and the impossibility of generalizing from it to the variety of settings in the world and in particular to settings with little or no access to skilled and/or facility-based care for childbirth. The panel agreed that a review of qualitative evidence should be considered.

Many interventions in postnatal care are applicable to most countries and settings. Some principles apply in all settings and for all time bands—e.g. standard precautions, maintenance of records, maintaining competencies, monitoring and evaluation. The panel asked the WHO secretariat to identify those common areas and include them in a preamble to the guidelines as “Principles of Good Care”. Health system requirements, however, may differ for different time bands and so will need more specific consideration. A tool for countries on how to select appropriate care pathways for specific settings, including health system requirements, would be useful.

The panel noted that some important situations were not addressed. While these situations are not the primary focus of the proposed guidelines, it is important to highlight special considerations in such situations. These include malnourished women (obese and undernourished mothers); domestic and gender-based violence; use of alcohol, tobacco, and illicit drugs; mothers who have lost their babies or have babies with disabilities; mothers with very limited education or with language difficulties; mothers with medical or mental health problems; the small baby; multiple births; sick or disabled infants or infants with congenital anomalies; infants of mothers with tuberculosis, malaria, HIV, or syphilis; and those born to sex workers. Such factors can lead to physical and mental ill health for both the mother and the baby, during the pregnancy and after, or may be linked to a negative nurturing environment with adverse long-term effects on infant health and development.

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