Correspondence:
Abdel-Hady El-Gilany
Prof. of Public Health, College of Medicine,
Mansoura University, Egypt
Family and Community Medicine Department,
College of Medicine in Al-Hassa
King Faisal University
P.O. Box: 400
Hofuf 31982
Saudi Arabia
e-mail: ahgilany@hotmail.com
Mobile: 00966/566482385

The postpartum period or puerperium includes the first six weeks after delivery of the placenta [1-3]. This period is a very special phase in the life of a woman. She is going through the physiological process of uterine involution and at the same time adapting to her new role in the family. Many postpartum complications occur during this period^[1,2,4]. Among the important obstetric morbidities are postpartum hemorrhage, pregnancy-related hypertension, pulmonary embolism and puerperal sepsis. The common surgical complications are wound breakdown, breast abscess and urinary fecal incontinence. Medical conditions such as anemia, headache, backache, constipation and sexual problems may also be present^[2,3].

Postpartum care is the most neglected aspect of maternity care and more research is needed on issues related to postpartum maternal health. Early postpartum care is essential to diagnose and treat complications^[5]. Although there is little evidence to support the timing and content of postpartum visits, there is evidence that this is a time of increased health needs for both mother and baby^[6]. Postpartum care visits provide opportunities to assess the physical and psychological well-being of the mother, counsel her on infant care and family planning and give appropriate referrals for pre-existing or developing chronic conditions^[4,5,7].

Utilization of reproductive health services, including maternal health care, is related to their availability, and socioeconomic, demographic and cultural factors such as women's age, education, employment and autonomy; and perception of women and their families regarding the need for care^[8-10]. In contrast to relatively high to moderate levels of antenatal care received by women in the Arab region, the coverage of postnatal care is markedly lower^[11]. In other regions of Saudi Arabia postnatal care coverage ranged from a very low rate of 6.5% in the Northern Region^[12] (12) and up to 52% in Abha Region^[13]. Postnatal care coverage ranged from 48-88% at the national level, according to different surveys^[14,15].

This study aims to assess utilization of postnatal care and to define the magnitude of postnatal maternal morbidities in Al-Hassa, Saudi Arabia.

This study was carried out in Al-Hassa, Saudi Arabia, during a period of four months from February 1 to the end of May 2007 G. Al-Hassa is located in the Eastern Zone of the Kingdom, bordering the Arabian Gulf. It is an agricultural area. The population is estimated to be about 800 thousands, distributed into urban, rural and hegar (Bedouin desert collections). Maternity care is provided through a network of 47 PHCCs, maternal and child hospitals, two small district hospitals in addition to the private sector and National Guard hospital and health centers.

After selection of PHCCs and nomination of nurses, the questionnaire was developed and pretested on 150 mothers (10 from each of the 15 PHCCs) to train nurses on data collection, reveal any difficulties and to estimate the percentage of mothers who received postnatal care. The pilot study revealed that it is necessary to review maternity cards and family files in addition to the interview with mothers.

The sample size was calculated using Epi Info 2004 software. From statistics of Al-Hassa Directorate of Health 15032 births were registered during 2006 G. With an expected postnatal care coverage of 51% from the pilot study, confidence interval of 95% and power of 80%, the number of mothers required was 1394. To overcome the attrition due to cluster sampling methodology, 30% were added. Thus, the final sample was 1812 mothers. This sample was distributed proportionally to urban, rural and Hegar localities.

Two-stage stratified sampling technique was used. The first stage is stratification of Al-Hassa into urban, rural and Hegar areas. At the second stage, five primary health care centers (PHCCs) were chosen from each stratum. These centers were chosen based on availability of an Arabic speaking nurse and their geographical distribution to represent different socioeconomic strata of the community.

Mothers were assured that data collected would be dealt with confidentially and the impact of the study would be respected, maintained and used only for research purposes and for improving services. Al-Hassa Directorate of Health approved the study and questionnaire and mothers gave verbal consent before the interview. There is no ethical research committee at the moment.

An Arabic speaking female nurse completed the questionnaires during interview with mothers two months after birth during a vaccination session in each center. Additional data was abstracted from both family file, maternity cards and hospital discharge forms kept in a family file at PHCCs. A maternity card has been developed to include the appropriate data on prenatal, natal and postnatal care, as well as a list of factors of high-risk pregnancy for referral purposes and maternal morbidities. The Ministry of Health has developed special guidelines for using the card, explaining its contents and how to use it, as well as defining the various measurements and investigation and their normal limits. It is shared by the health centers and hospital. There is continuous stress on completeness of this card.

The outcome variable is receiving one or more postnatal check ups by a health care personnel, whatever its source.

Data were analyzed using SPSS (Statistical Package for Social Sciences) version 11. Descriptive statistics were done. The chi-squared test was used to find significance between categorical variables. Significant predictors of receiving postnatal care in univariate analysis were entered into multivariate stepwise forward Wald logistic regression analysis. Odds ratios and their 95% confidence intervals were presented. P=0.05 was considered statistically significant.

The study covered 94.7% (1996 out of 2108) of mothers who gave birth in the catchment areas of 15 primary health care centers during the study duration. No maternal mortality was recorded.

Table 1 reveals that more than 50% of mothers never received postnatal care and PHC centers were the most common source of care. There was no postnatal home visit. The main reasons for not seeking postnatal care were absence of health problems, busy husbands, the false idea that postnatal care is not necessary (Table 2).

Table 3 shows that mothers with long pregnancy spacing, mothers who received antenatal care at private clinics, and gave birth at private clinics and those with postnatal morbidities are more likely to receive postnatal care. Logistic regression analysis revealed that the independent predictors of seeking postnatal care are presence of postnatal morbidities, prolonged pregnancy spacing and seeking care at private clinics (Table 4).

The commonest postpartum morbidities were breast engorgement/abscess (4.1) and infected episiotomy/ perineal tear (1.9%) (Table 5).

†Among 995 mothers seeking postnatal care.
‡shared care between PHCC, hospital and/or private clinics.

†Among 1001 mothers not seeking postnatal care and categories are not mutually exclusive.

†Primigravidae were excluded, ## Non-attenders for antenatal care were excluded.
*** P£0.001

OR= Odds ratio, CI= Confidence Interval, r= reference group

Currently, the primary health care program of the Kingdom of Saudi Arabia has become well established, with the attainment of a very wide coverage. Maternal care is the responsibility of physicians assisted by the nurse and midwives^[14]. Health care services provided by the governmental sector in Saudi Arabia account for over 80% of total services and are almost provided free of charge. Health care is also provided by other agencies e.g. National Guard, ARAMCO Petroleum Company and the private sector^[15].

Like antenatal care, the postpartum care that typically occurs during the six weeks after childbirth is considered important to a new mother' health. Unlike the tracking of prenatal visits, however, few statistics exists on postpartum health care utilization or postpartum health problems. Thus, postpartum care is a neglected aspect of women's health care^[16,17].

About half of mothers received postnatal care; most of them attended once and only 1.6% attended twice to the health facility; there were no home visits. Reasons cited for not seeking postnatal care were mainly absence of health problems, and no need for care, mother's ignorance about the importance of postnatal care as well as busy husbands. This relatively high rate of postnatal check-up may be attributed to the policy followed in some PHCC that mothers should attend for check-up as a pre-requisite for registration of newborns. This is evident from the finding that most mothers received a postnatal check-up at the PHCC. Mothers attending postnatal care at hospitals and private clinics are most probably those with morbidities necessitating specialist consultation or hospitalization. Further evidence is that presence of postnatal morbidities is the strongest independent predictor of receiving postnatal care in general.

This coverage rate is much higher than the rate of 6.5% reported from the Northern Region of the Kingdom^[12]. However, it is lower than the 52% coverage reported from Abha Region^[13]. Review of the data from the Saudis National mothers and child health surveys of 1987 and 1990 showed that the percentage of mothers who received postnatal care increased from 58% to 88%^[14]. Rates of postnatal care from other developing countries were reported to be 34% in Nepal^[18], 33% in India and 84% in Zambia. In USA, 98% of mothers participated in a Pregnancy Risk Assessment Monitoring System received postnatal care^[7].

It was reported that lack of awareness is the main barrier to the utilization of postnatal care. Women's own occupation, number of pregnancies, children, and husbands' socioeconomic status, occupation and education were significantly associated with the utilization of postnatal care^[7,18]. In Saudi Arabia, there are a lot of problems concerning the understanding of postnatal care home visits:

1. the mother and her family do not realize the need for postnatal care,
   
2. traditionally, because of fear of the evil eye, nobody is allowed to see the mother or her baby,
   
3. many health staff are expatriate who do not understand the language or local customs, so they are not accepted at home level,
   
4. problems regarding the need for somebody to accompany a female to home in addition to the driver,
   
5. transport may not be available for home visits,
   
6. male doctors find it difficult to examine female patients,
   
7. delivery may take place at home, in other region or in a private clinic without communication with health centers,
   
8. nursing staff may face isolated, unforeseen bad experiences at home level and (9) home visits are less likely and may not be welcomed for cultural reasons^[21].

In Saudi Arabia, women are not allowed to drive cars so husbands or other adult male family members need to accompany her to the health centre.

Maternal morbidity refers to complications that have arisen during pregnancy, delivery or the past-partum period^[19]. Postpartum morbidities continue to be major health issues that need to be looked into critically, not only for curative but also for preventive and promotive care^[22]. About 5.4 % of mothers reported one or more severe postnatal morbidities. A higher percentage of mothers with postnatal morbidities, up to 42.9%, was reported from other countries^[23,24].

The commonest morbidities encountered were breast abscess/engorgement, infected episiotomy/perineal tear and urinary tract infection. In the Northern region urinary tract infection, puerperal sepsis and postpartum hemorrhage were the commonest postnatal morbidities(12). In the Saudi Arabia Family and Health, about 7% and 6% of respondents reported having severe bleeding and fever, respectively, after delivery^[15]. In other countries, the main disorders for which postpartum women sought care were puerperal sepsis, secondary postpartum hemorrhage and postpartum eclampsia. The commonest cause of sepsis was infected episiotomies or tears^[19,22-24].

In conclusion, postnatal care is deficient in coverage and number of visits. To improve postnatal care there is a need to establish adequate outreach services in catchment areas. PHC staff should routinely trace defaulting mothers through telephone communication or home visits. Importance of postnatal visits should be communicated to all women at the time of antenatal care and discharge from the hospital after delivery. The policy of obligatory postnatal check-up as a pre-requisite to register of newborns implemented in PHCC can be generalized to all health centers. A clear policy about quality, number, timing and contents of postnatal check-ups will contribute to increase postnatal care coverage. In-depth qualitative study is warranted to explore the socio-cultural and behavioral factors impeding postnatal care.

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