By Brian Tena Tena Aussak, former EngenderHealth DRC; Jocelyne Kibungu, EngenderHealth DRC; and Rebecca White, Consultant, London School of Hygiene & Tropical Medicine

Sifa¹, aged 33, went into labor with her second baby on March 11. After a few hours, the baby was born by cesarean section at Saint Joseph Hospital in the Democratic Republic of Congo (DRC). Recovery in the hospital went well and Sifa was discharged six days after giving birth.

On her first day at home, Sifa noticed bleeding from her cesarean wound. She sought help at her closest health center and spent the next few days traveling back and forth for fresh dressings. But she continued to bleed. On March 26, 15 days postpartum, her mother took her back to Saint Joseph Hospital. Sifa had all the signs of severe anemia – an unhealthy pale appearance, vertigo, low blood pressure, and fast heart rate – which was confirmed with blood testing. She was treated with a blood transfusion while the hospital team investigated the cause of the bleeding. She was rushed for surgical intervention and yet another blood transfusion to replace what she was losing. In total, Sifa had more than half of her blood volume replaced. Sifa remained in hospital for another month to ensure that she was infection-free and recovered from the blood loss before returning home.

It could have been even worse. If Sifa’s mother hadn’t intervened and taken her to Saint Joseph, she likely would have died at home. But it also could have been much better. If there had been a process for follow-up after discharge from hospital, Sifa could have received care sooner, avoiding multiple blood transfusions and a long-term hospital stay. She could have been at home with her family and new baby rather than in the hospital. Cases like Sifa’s can be prevented. But to do that, our thinking needs to shift from just helping mothers and newborns survive delivery, to helping them thrive afterwards. We need to look at the postpartum period.

The postpartum period is neglected

“It [the postpartum period] is a critical time for women, newborns, partners, parents, caregivers and families. Yet, during this period, the burden of maternal and neonatal mortality and morbidity remains unacceptably high.” – World Health Organization (WHO) 

The postpartum period is defined as the first 42 days (or 6 weeks) following birth. Each year, hundreds of thousands of mothers and babies around the world die during this period and many more experience adverse mental and physical health outcomes. Eventful childbirth experiences are a risk factor for poor postpartum health outcomes, particularly for those who had surgical interventions.

The frequency of ill-health, including mental health, in the postpartum period is poorly understood as many maternal and neonatal health studies do not collect data beyond discharge from a health facility. This is especially true for mothers in low- and middle-income countries (LMICs). Research in 33 sub-Saharan African countries found that a third of women do not receive a single health check between delivery and health facility discharge.² The limited data available worldwide paints a compelling picture for investment in postpartum care. The European Centre for Disease Prevention and Control have previously shown that 85% of infections after cesarean delivery were diagnosed after discharge,³ and that countries with more intensive post-discharge surveillance methods identify more surgical site infections.⁴

Yet the six-week postpartum period receives relatively little attention within health systems. As seen in Sifa’s case, once the mother leaves the facility, the continuum of care often stops. As more of the world’s population shifts to delivering in healthcare facilities, a seamless continuation of care beyond the health-facility setting has a vital role to play in detecting and managing complications and ensuring the health and wellbeing of both mothers and newborns.

A positive postpartum experience

The need for more evidence and support has been recognized by WHO. They have published guidelines on delivering a ‘positive postnatal experience,’ which call for at least three contacts in the six weeks postpartum.⁵ The guidelines also stress that postpartum care needs to shift from survival and coverage into quality of care to meet the human-rights based approach of the Sustainable Development Goals. WHO characterizes a ‘positive postnatal experience’ as one “in which women, newborns, partners, parents, caregivers and families receive information, reassurance and support in a consistent manner from motivated health workers; where a resourced and flexible health system recognizes the needs of women and babies and respects their cultural context.”

So, the first vital step has been taken: recognizing the neglect. But the question now becomes: How do we quantify and then solve the problem? That’s where the work of MOMENTUM Safe Surgery in Family Planning and Obstetrics Postpartum Surveillance by Telephone (PARLE) study comes in.

Collating the existing evidence

The first critical step the PARLE team took was to start a scoping review to look at ways of capturing health issues postpartum beginning early in 2023.⁶ They found 31 studies with useful information on methods for post-discharge follow-up in the postpartum period categorized as in-person visits, telephone calls, self-administered questionnaires, or a combination of these.

One of the leads of this work is Professor Oona Campbell, a reproductive health and epidemiology specialist at The London School of Hygiene & Tropical Medicine. She elaborated on the importance of their initial research and finding appropriate solutions for LMICs:

“Limited research has been conducted to identify the most effective methods to follow up with women post-discharge, particularly in low-resource settings, and we were unable to find an existing systematic review of this topic. So, we decided to start there. Approaches to follow-up are likely to differ between high- and low-resource settings. Many of the approaches used in high-resource environments simply wouldn’t work in a low-resource setting. For low-resource settings, follow-up methods should be low-cost, efficient, valid, and not rely on individual-linked electronic records or functioning postal systems.”

By taking a global approach and capturing the range of follow up methods currently employed, the PARLE team was able to identify a promising solution that could work well for low-resource settings: using mobile phones to ask women about their health. With the huge global increase in mobile phone ownership and connectivity, they are a potential way to reach women who otherwise would not have contact with a healthcare provider during the postpartum period.

Phone-based surveillance in DRC

Having identified this promising solution, the PARLE team is now conducting a phone-surveillance demonstration study in DRC, a country where women have a need for postpartum contact with health services because of a significant burden of maternal and newborn ill health (see text box). Despite 85% of births occurring in health facilities, the maternal mortality ratio (MMR) was estimated at 547/100,000 live births in 2020, nearly eight-times higher than the global target set in the Sustainable Development Goals (70/100,000 live births) and over 100 times higher than the MMR in countries like Japan, Australia, or Belarus (MMR < 5/100,000 live births).⁷ 

Led by a DRC-based team of experts, the study aims to recruit 660 women who recently had a cesarean delivery from one of three study hospitals. Women with cesarean deliveries were selected because they are a key target population of the MOMENTUM Safe Surgery in Family Planning and Obstetrics project, and they tend to have more postpartum complications than women with vaginal deliveries. Hospital staff are conducting up to three phone interviews in the 28-days following discharge from hospital. The team chose 28 days based on evidence that most cesarean delivery infections are picked up within the first 20 days after delivery, 28 days marks the end of the neonatal period, and similar studies in Kenya and Tanzania called women around 30 days.⁸ During these calls, the study team will assess the physical and mental health symptoms the mother or baby have experienced since birth and connect them to follow-up services if needed. In addition, staff members in each hospital will be interviewed to understand their perspectives on the feasibility and sustainability of the process.

Professor Campbell elaborates on the hopes for the research:

“The study will help us to confirm whether telephone interviews with women are a feasible way to conduct postpartum assessments and if this can provide us with valuable data on the frequency of complications in the postpartum period. Whether phone surveillance proves to be a feasible strategy or not, the process involved in this study will contribute to improved routine follow-up of mothers and babies after delivery, especially cesarean delivery, and will be relevant to identifying quality improvement interventions…By describing the frequency of postpartum infection and other conditions, it will be possible to highlight the problem for policymakers and practitioners and make this a priority for them. Ultimately, it’s about improving care for mothers like Sifa and their babies and preventing adverse outcomes.”

By the end of the study, the PARLE team will evaluate if a telephone questionnaire with women who have had a cesarean delivery is useful in capturing the number of physical and mental health symptoms and outcomes for mother and baby.

If this model of post-discharge follow-up works, then implementation and scale up will require investment and advocacy. So, a crucial final step is assessing the feasibility of incorporating this type of information-gathering model into routine hospital services. If successful, it could create a blueprint for other sites within DRC and beyond to follow, ultimately helping more women like Sifa get the help they need, and sooner.

Contributors: Maxine Pepper, Sara Malakoff, Don Félicien Banze, Jean Lambert Chalachala, Oona Campbell, Renae Stafford, Farhad Khan, Karen Levin, Vandana Tripathi, and Ona McCarthy on behalf of the PARLE research team