Strengthening postnatal care in Gaza: A home-visiting programme for mothers and newborns
Amani Jouda is the Early Childhood and Development Officer in the UNICEF Gaza field office.
Selena Bajraktarevic is Chief of the Health and Nutrition programme with UNICEF, State of Palestine.
Younis AwadAllah is a health specialist in the UNICEF Gaza Field Office.
Shereen Obaid is a monitoring and evaluation specialist with UNICEF, State of Palestine.
Background
The Gaza Strip, or Gaza, is a self-governing Palestinian territory with a population of around 1.85 million on the eastern coast of the Mediterranean, bordering Egypt and Israel. The health sector in Gaza has been heavily disrupted by years of conflict, sanctions and socioeconomic decline. Healthcare services and clinical staff are overstretched and lack basic resources, with frequent power cuts and stock-outs of essential drugs and equipment1.
Maternal healthcare in Gaza is an integral component of the health service. Annually in Gaza there are between 50,000 to 60,000 deliveries, with around 160 children born per day. Nearly all deliveries are institutionalised; a quarter of women gave birth with assistance from a midwife/nurse and three quarters by a physician2. However, more than half of the women (58%) stay less than six hours in the facility after they give birth due to overcrowding in maternity wards, and postnatal care remains at an unacceptable level in terms of coverage, quality and the frequency of visits of women to health centres for postnatal checkups.
Strengthening postnatal care
Postnatal home visits in the first week of life are strongly recommended by the World Health Organization (WHO) to improve maternal and checkups outcomes. Considering the context and the current situation in Gaza, the nutrition risks and vulnerabilities among pregnant and lactating women and infants, particularly newborns, are high. For example, micronutrient deficiencies are high, with 75% of children under one year of age being anaemic and an estimated 30% of pregnant and lactating women suffering from anaemia3. Less than 50% of infants are exclusively breastfed to six months of age4.
In 2011 a postnatal home visiting (PNHV) programme was set up to tackle these issues for high-risk pregnant and lactating women and newborns, usually within the first three days following delivery. The Ministry of Health (MoH) is the main partner, with support from UNICEF, and aims to offer the programme to 6,000 women and their newborns in all five governorates in Gaza.
Developing the programme
The PNHV programme is implemented by a cadre of 45 trained midwives from MoH and partners, who receive annual refresher training. The main maternal nutrition care provided to the mother includes measuring haemoglobin and blood glucose levels. Mothers are counselled on the importance of nutritious food and taking iron tablets and they are referred to health centres for iron supplements where required. Such advice is provided alongside other services, including checking the mother’s vital signs (temperature, pulse, respiration and blood pressure). Care for the infant includes weighing and measuring length and providing advice on exclusive breastfeeding and responsive parenting, alongside assessing the newborn for any developmental delays, with referral if needed.
Programme evaluation
An external evaluation of the PNHV programme was conducted in June 2018, covering the 2011-2016 period. Around 130 people, including home visitor midwives, mothers, fathers and key informants, were interviewed. However, the lack of a baseline and a robust monitoring and evaluation system has made it difficult to give statistical evidence on programme impact, so findings of programme effectiveness are limited to qualitative and observational data.
In general, the PNHV programme is thought to have increased the capacity for home visits to promote infant and young child feeding, and encourage exclusive breastfeeding and support for non-breastfed infants where needed. The evaluation found that community and home-based activities had increased mutual understanding and respect between health providers and women. This had helped midwives conducting the home visits to establish stronger relationships with mothers, building trust and enabling mothers to ask more questions about their own health and that of their babies.
Benefits to mothers and midwives
Mothers interviewed said the programme had been quite effective in stopping potentially harmful traditional practices, such as giving infants herbal teas, use of crystallised sugar to treat jaundice and use of bitter substances for weaning off breastmilk. There was a very high satisfaction rate among participating mothers, who reported increased self-esteem and confidence.
Midwives had also gained new insights in their training as home visitors, especially on nutrition, breastfeeding and hygiene practices, but also on early childhood development (an area that had been recently included in their role). Moreover, health providers and key informants cited key successes where they saved lives or detected complications for referral in timely fashion, although these had not been measured in the evaluation.
Addressing challenges and lessons learned
The evaluation also highlighted a number of ways to enhance the quality of postnatal care and to better integrate such care into maternal and child health services. Recommendations include standardisation of postnatal guidelines, harmonisation of services provided by all stakeholders, and building a centralised information system to document and monitor programme implementation. Due to financial constraints, the programme has had to focus on women with high-risk pregnancies/deliveries and first-time mothers, rather than covering all households. However, the PNHV programme needs to address concerns about the absence of a holistic postnatal care approach and lack of an updated protocol in order to ensure sustainability of continued external funding. Furthermore, there was no specific strategy to engage fathers and extended family members, such as grandparents.
Home visits facilitated a more personalised approach and allowed a deeper understanding of problems that women in the programme were facing. The mothers realised that they need postnatal care for themselves and not only for their infants. In addition, home visitors were able to provide enhanced services through building stronger relationships with beneficiaries, and postnatal care was perceived as a routine aspect of their role. Providing high-quality PNHV services, including better targeting and criteria for selection of high-risk pregnant and lactating women, is extremely important for successful outcomes. However, documenting and evidence-based programming should be considered from the beginning until the end of an intervention.
Footnotes
1UNRWA Report. www.unrwa.org/activity/health-gaza-strip
2Palestinian Central Bureau of Statistics (2015); Palestinian Multiple Indicator Cluster Survey (2014) Final Report, Ramallah, Palestine.
3Ministry of Health (2016) Nutrition Surveillance.
4UNICEF. Health and Nutrition Profile, Palestine. www.unicef.org/sop/what-we-do/health-and-nutrition