Celebrating mother and child on the fortieth day: the Sfax, Tunisia, postpartum programme
Presented by Mrs Fatima Attaya-Gargouri, Sfax Regional Delegate of the National Office of the Family and the Population, Tunisia
The Maternal and Neonatal Hospital of Sfax is a 136-bed hospital where 11,000 births take place annually, representing 65% of births in the region. This was an ideal setting for carrying out a major objective of the national family planning programme to provide information and services that would allow all women who were interested in preventing or delaying their next pregnancy to begin practising contraception as soon after delivery as appropriate. The hospital was able to give access to a broader range of services to a large number of women of childbearing age. However, despite the natural overlap between maternal and child health, and pregnancy spacing or prevention, the relevant services in Sfax were running on separate tracks: staff in maternity considered family planning someone else’s business and family planning staff focused only on contraceptive use. As a result, each programme was targeting specific needs of women related to its own services only, overlooking their overall needs.
In 1983, in an effort to solve these problems by providing integrated maternal health care, family planning services and well-baby care, the hospital launched an innovative postpartum programme that treated mother and child as a synergistic pair - a follow-up visit was scheduled for every mother and child 40 days after the birth. The 40th day was chosen because of its great cultural significance in Muslim societies. It marks the end of a convalescence period for the mother and the beginning of a new stage of development for the child. Until the fortieth day, the mother is exempt from all her household duties, is provided with nutritionally rich foods, and is restricted from leaving the home, bathing or engaging in sexual activity. On the fortieth day, these restrictions are lifted and often a celebration is held to mark the occasion.
A permanent family planning educator was hired to make direct contact with mothers who had just given birth and to invite them to attend the free medical consultation 40 days after the birth. This educator was also given responsibility for organizing group and individual meetings to demonstrate contraceptive methods and to help women select an appropriate method. A radio programme broadcasting a range of educational messages on the importance of breast-feeding and family planning was also set up in the hospital.
On the return visit, the child is immunized and examined by a paediatrician. The mother is given a gynaecological check-up and is presented with a range of contraceptives to choose from free of charge. Follow-up and further contraceptive supplies are provided by the local family planning centre, for which the mother is given an appointment card.
This integrated postpartum family planning programme has gone a long way towards meeting its objectives. In 1983, when the programme was first implemented, 60% of women who had given birth at the maternity unit returned for the fortieth day visit. By 1987, this proportion had increased by 23% and now stands at over 85% (Figure 7). Of the women who returned in 1987, 56% accepted a family planning method during their visit. Over 75% opted for a modern method (rather than the rhythm method or reliance on breast-feeding), with 42% choosing a contraceptive foam or condoms.
The post-partum programme’s “40-day” return rate at Sfax hospital, Tunisia
Once the programme was well established, efforts were undertaken to make the services even more effective for the women who used them. To this end, an analysis was carried out in 1988 to investigate why 44% of women left after the 40 day visit without choosing any family planning method. Of the explanations that emerged, having been diagnosed with gynaecological problems was significant, accounting for 46% of the reasons (the programme considers gynaecological infections as a contraindication to lUDs and tubal ligation). With obvious implications for STD prevention, this discovery led to the decision to dispense spermicides and condoms to infected women, placing particular emphasis on the role these methods can play in reducing the spread of infection. Prior to this, foam and condoms were given only to those women who specifically requested them. The programme is currently seeking ways to add the capacity to diagnose and treat the large number of women presenting with vaginal discharge, rather than referring them for treatment.
A number of factors have contributed to the success of this programme including the fact that the appointment is scheduled for both the child and the mother together at the same time and in the same place, free of charge and that the date of the appointment is linked with the fortieth day after delivery, a day that has both cultural and religious significance for the Tunisian mother and infant. This programme not only capitalizes on a date that has a meaning for the mother and can be easily remembered, but also responds to the mother’s concerns for her child’s health, a concern that is often more pressing to her than her own needs.
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