MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH 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 Code: 62.72.76.01 ABSTRACT OF PhD DISERTATION   HANOI, 2014   This work has been completed at National Institute of Hygiene and Epidemiology Supervisors Asso.Prof Vuong Tien Hoa, MD PhD., 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 , date month .year 2014 Full dissertation could be found at - National Library - The library of National Institute of Epidemiology and Hygiene   LIST OF PUBLISHED ARTICLES RELATED TO DISERTATION 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 (125), pp.165-174 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 (133), pp.124-132 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   ABBREVIATIONS BPTT CS CSTN CSSS CSHQ HQCT Ptct Psct KHHGĐ PSTW SKSS TCMR TCYTTG Contraceptive methods Care Home-based care Postnatal Care Efficiency index The efficiency of Intervention Propotion before intervention Propoption after intervention Family Planning National hospital of Obstetrics and Gynecology Reproductive Health National Immunization Program World health organisation Biện pháp tránh thai Chăm sóc Chăm sóc nhà Chăm sóc sau sinh Chỉ số hiệu Hiệu can thiệp Tỷ lệ trước can thiệp Tỷ lệ sau can thiệp Kế hoạch hố gia đình Phụ sản trung ương Sức khỏe sinh sản Tiêm chủng mở rộng Tổ chức Y tế giới   INTRODUCTION 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: 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 Evaluating effects of home-based postnatal care service on mothers giving birth at the two hospitals 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 Structure of dissertation: This paper includes 131 pages, divided in chapters that consist of Introduction: pages, Chapter 1- Overview: 27 pages, Chapter2Subject&Research methods: 19 pages, Chapter 3- Results: 51 pages, Chapter 4- Discussion: 29 pages, Conclusion: pages and Recommendations: page It contains 45 tables, charts, objects and a map The paper presents 113 references that include 44 Vietnamese and 67 English and a full questionnaire Chapter OVERVIEW 1.1 Overview of postnatal care at community 1.1.1 Basic concepts: - Postnatal period contains postpartum (in weeks after birth) and newborn period (in weeks after birth) - According to WHO, definition of postnatal care included all monitoring, referral for any maternal complications such as hemorrhage, pain, infection, and all form of counseling on breastfeeding, nutrition, newborn care and family planning Newborn care includes early breastfeeding, keeping warm, cord care and detecting dangerous signs for examination and treatment 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 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 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 2.2.1.3 Sample size: - For mother Use the formula: p(1-p) n= d2     = In which: Z 1-α/2 1,96, with accuracy of 95% , d=0,05 is selected odd p: % women having good knowldge on postnatal care according to previous study of Lê Thị Vân, 2003 is 40% q =(1-p): % women having poor knowledge of postnatal care = 60%, The sample size is calculated to be 368.  Taking sample at different areas of rural and urban, we have each subject group having 368 women Sum of total women in two areas, we have 736 women needed for the study In fact, we recruited 762 women, of which rural area: 373 women, urban area: 389 women - Subject 2: Family representatives (Care taker) In each area, we chose 10 informants for in-deph interview   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 2.2.2.3 Sample size: - Quantitative study: Subjects are women afterbirth Use teh formular as the followings: n1 = n2 = [Z(1−α / 2) p(1 − p) + Z1−β [ p1 (1 − p1 ) + p2 (1 − p2 ) ]2 ( p1 − p2 )2 In which: n1: sample size of study group, n2: sample size for control group, P1: % women having good practice on postnatal care (PC) 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 = 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 2.3.5 Assessment An assessment score on mothers' knoewledge and practice on postnatal care has been used in the study Total score of knowledge is 42, of which 13 for detecting dangerous signs, 10 for hygiene -labour, 10 for nutrition and for family planning methods Total score of practice is 15 If 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 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   10 Table 3.22 Nutrition practice in postnatal period by living area Contents Urban Rural Total N=389 n=373 n=762 n % n % N % As usual 24 6,2 26 7,0 50 6,6 Bigger than usual 319 82,0 294 78,8 613 80,4 Meal restriction 46 11,8 53 14,2 99 13,0 Yes 0,8 0 0,4 No 381 97,9 369 100 750 99,6 Full dose 96 27,4 130 35,1 226 31,4 Less dose 35 10,0 79 21,4 114 15,8 No taking 219 62,6 161 43,5 380 52,8 Yes 377 96,9 362 97,1 739 97,0 No 12 3,1 11 2,9 23 3,0 Meal amount Vitamin A taking Iron table taking Intensive breast feeding The rate of mothers reported taking Vitamin A and Iron tablets in postnatal care period is low There is only 0,4% of mothers use Vitamin A and 15,8% of mothers taking full dose of Iron tablet The rate of mothers taking supplements afterbirth in rural group is more than this in rural group (21,4% compared with 10% respectively) The rate of intensive breastfeeding is high: 97% 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   11 35,3% 64,7% Pass False Figure 3.4 Mothers' general practice on postnatal care The rate of mothers having good practice on PC in this study is 34.6% that very close with this of 35.4% in Le Thi Van's study in 2003 3.1.4 Related factors to mothers' knowledge and practice on postnatal care Study results showed age group of mother, number of living children may influence to their knowledge and practice of PC In particularly, mothers at 30 years old and above; have from children are eligible to have good knowledge and practice of PC from 2.8 to 3.3 times higher than those are at under 30 years old and having only one child Table 3.26 Association between knowledge and practice of PC Knowledge of Practice of PC mothers on Passed False Total Postnatal care Passed 391(79,5) 95 (34,9) 486(63,7) False 101(20,5) 175(65,1) 276(36,3) Total 492 (100) 270 (100) 762(100) OR, CI 95%, p OR=7,2; CI: 4,9- 10,4, p