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Abstract

Despite the efforts made in Ethiopia to decrease maternal mortality by increasing postnatal care and other maternal health care services, neither significant reduction in maternal mortality nor an increase in postnatal care utilization. The objective of this study was to develop an action plan to improve postnatal care services in the Ethiopian context. Sequential mixed-methods research, was conducted over three phases. In the first phase of the study, background information on postnatal care services in Ethiopia was assessed and described. During the second phase of the study, an action plan for postnatal care improvement was developed, and the third phase concentrated on the validation of the developed action plan. For phase 1 one of the study 422 respondents were randomly selected and participated in the study from November 1 to 30, 2020. A self-administered structured questionnaire was used for quantitative data collection. The collected data were checked for completeness, cleaned, coded, and then entered into Statistical Package for Social Sciences (SPSS) software program version 21. For the thrird phase of the study a delphi technique was used to validate the developed action plan . For all phases of the study, the open-ended questions were open-coded and thematically analyzed. A validated action plan for the improvements of postnatal care was developed using the inputs from respondents during Phase 1, available literature as well as the three-round Delphi technique. The findings revealed that the developed action plan is applicable in the Ethiopian context and is crucial for improvement of postnatal care. The study revealed that the developed and validated action plan will improve postnatal care in Ethiopia. Follow-up studies to assess the limitations of the action plan can be conducted to adapt and improve the action plan. Further studies on possible challenges associated with the implementation can enhance the success of the implementation of the action plan.

Keywords

an action plan for implementation improved postnatal care maternal mortality maternal health Ethiopia

Background

Maternal mortality remains high in most developing countries (WHO, UNICEF, UNFPA, WB & UNPD, 2014) where 99% of all maternal deaths occur (WHO, UNICEF, UNFPA & the WB, 2015). This high proportion of maternal deaths that occurs during the first 48 hr after delivery is mostly preventable if women receive optimal postnatal care (Atuhaire et al., 2020; Sakala & Chirwa, 2019). Evidences indicate that the postnatal period is a critical time when more than 60% of maternal deaths occur, and about 45% of postpartum maternal deaths occur on the first of delivery. Health professionals can, can diagnose any postpartum problems and complications during the postnatal period to ensure prompt treatment or interventions (World Health Organization [WHO], 2014). The provision of quality and timely postnatal care after birth is very important to promote healthy practices, such as exclusive breastfeeding, and immunization which are key to the health and survival of the newborn baby (Aziz et al., 2022; WHO, 2014). Therefore, accessible and quality postnatal care for mothers and newborns can decrease maternal and neonatal mortality and morbidity rate in any country (Adhikari et al., 2016).

Even though postnatal care services have many advantages, in most developing countries including Ethiopia, it is generally the most neglected maternal and child health services (Mukinda et al., 2021; Sultana & Shaikh, 2015). The utilization of postnatal services from competent health professionals such as midwives, nurses, health officers, and others who have the competency to render these services is very low in most developing countries including Ethiopia (Somefun & Ibisomi, 2016). The level of postnatal care utilization in Ethiopia is extremely low: 81% (Central Statistical Agency [Ethiopia] and ICF International, 2016) of those who gave birth to a live baby between 2011 and 2016 did not receive any postnatal care. The timing of receiving the service is also a concern as only 17% of women who have received postnatal care received it within 2 days after delivery, as recommended by the WHO (Central Statistical Agency [Ethiopia] and ICF International, 2016; WHO, 2014).

In Ethiopia, despite the implementation of different strategies, to decrease maternal mortality by increasing postnatal care and other maternal healthcare services, no significant reduction in maternal mortality or an increase in postnatal care utilization was achieved (Central Statistical Agency [Ethiopia] and ICF International, 2016). To address different aspects and barriers to postnatal care services, there is a need to have an action plan in Ethiopia. Hence, developing an action plan to improve postnatal care was deemed a possible intervention for improvements of postnatal care services in the Ethiopian context. The developed action plan has the potential to improve postnatal care in Ethiopia. The findings from the study will also contribute to existing knowledge on postnatal care through publications of the results in peer-reviewed scientific journals. This findings from this study can also be an input for policy makers and planners in Ethiopia.

Methods

Study Design, Period, and Area

A sequential mixed-method approach that included both quantitative and qualitative data-gathering techniques was used (Johnson, 2019). The study was employed in three phases. The first phase involved the assessment of postnatal care services in Ethiopia using validated self-administered questionnaires. The second phase was the development of the action plan using the data gathered in Phase 1 as well as the available literature. The third phase was concerned with the validation of the developed action plan.

The study was conducted in the Oromia Regional State; one of the nine regional states in Ethiopia, which is located in the center of Ethiopia from November 1–30/2020 (Ababa & Calverton, 2018).

Population

Key postnatal care providers and coordinators in Ethiopia who were working at different health facilities and departments in Oromia Regional State formed the population of the study.

Sample Size and Sampling Technique

The sample size was calculated using single population proportion formula with the following assumptions :

$n = \frac{{(Z_{α / 2})}^{2} \times p (1 - p)}{d^{2}}$ (1)

n = number of the study subjects

Z = is the standardized normal distribution curve value for the 95% confidence interval (1.96)

p = .5 (The expected proportion of women practicing proper genital hygiene).

q = 1-P = 0.5 (The expected proportion).

d = the desired precision of the estimate (the margin of error between the sample and population 5%)

Therefore, in phase 1, a total of 422 sample size was determined.

As a sampling frame, Lists of study participants were taken from the health facilities and health offices where they were working, and simple random sampling was used to select study participants. The identified population is the key contributor to the improvement of postnatal care in the Ethiopian health system.

Data Collection Tool, Procedure, and Analysis for Phase 1 of the Study

A self-administered structured questionnaire was developed and used to collect data on postnatal care services in Ethiopia in phase 1 of the study. A pre-test was conducted among 5% of the sample size that had similar characteristics as the study participants but was selected from health facilities located outside the study areas. Validation of the data collection tool was made by experts in the subject area. Ten data collectors were purposively selected for data collection. Before the initiation of data collection, the researcher conducted a 3-day training for the data collectors and supervisors.

For phase 1, the collected data were Data was checked for completeness, coded, and analyzed using SPSS software program. The Data were summarized and presented in tables and pie-charts using frequencies and percentages. In phase 2 of the study, based on the findings from phase 1 of the study and available literature, an action plan was developed.

In Phase 3 of the study, where the action plan was validated, a qualitative approach specifically the Delphi technique was followed to gather data (de Mello Pereira & Alvim, 2015). The Delphi technique was conducted among a panel of experts who are knowledgeable and experienced in postnatal care (Niederberger & Spranger, 2020). In this phase of the study, the researcher conducted three rounds of Delphi to reach a consensus and thus had a validated action plan for implementation within the Ethiopian context.

Eighteen Delphi panelists (12 district, 3 regional, and 3 national postnatal care coordinators) were purposefully selected to volunteer to participate. Once the panelists were selected, the objectives of the study and its contribution to postnatal care services in Ethiopia were communicated to them. The panelists were thus experts who understood postnatal care and its challenges, as well as the relevant concepts of postnatal care. The draft action plan with the embedded validation instrument was developed. The developed action plan and embedded validation instrument were loaded on Google Forms, an online survey method that the researcher used to gather data for the validation of the action plan for implementation.

The validation instrument included all important items namely: (1) action statements with Likert-scale options, (2) questions concerning the responsible bodies for the action, and (3) question items on the time frame in which the action must be implemented. In addition to the response options, the validation instrument had an open space where the panelists provided their views and recommendations to improve the draft action plan for postnatal care improvement. Before the commencement of round 1 of the Delphi process, a pre-test was conducted to test whether the Delphi panelists understood the embedded validation instrument (Ky et al., 2020).

Data Gathering for Phase 3 of the Study

After receiving the email addresses of postnatal care coordinators, who volunteered to participate, the recruitment letter was shared. By clicking on the link provided, the panelists indicated their consent to participate and obtained access to the validation instrument.

Data Analysis for Phase 3 of the Study

The responses from closed-ended questions were analyzed by the software program used by Google Forms and the researcher received the analyzed data from the Google Forms software. The consensus status was decided to be 75% cut-off point, as suggested by Keeney, et al. (2006; Barrios et al., 2021; Niederberger & Spranger, 2020). For items where consensus was not reached, the changes and recommendations were implemented into the action plan for implementation, and re-sent to panelists for inputs in the second round. The process continued for subsequent rounds until a consensus was reached. Thereafter, feedback was incorporated into the action plan for implementation, as suggested by Keeney et al. (Niederberger & Spranger, 2020).

The open-ended questions were open-coded and thematically analyzed as suggested by Creswell (Khan & MacEachen, 2022); thus, direct statements or responses were coded and grouped into themes or categories.

Results and Discussions

Phase 1 Findings

In phase 1 of the study, 422 respondents received and completed the questionnaire and in phase 3 of the study 18 panelists participated in all three rounds, thus a 100% response rate was achieved in all rounds.

Socio-Demographic Characteristics of the Respondents (N = 422)

The respondents’ Socio-demographic characteristics are presented in Table 1. Of all the respondents, 142 (f = 33.6%) were 30 to 39 years old, and 122 (f = 28.9%) were 40 to 49 years old (refer to Table 1). This indicates that very high proportion of health professionals were in the productive age that positively influences postnatal care services (Dlamini, 2016). Of all respondents, 248 (f = 58.8%) were females and only 174 (f = 41.2%) were males (refer to Table 1). This ratio is different from the national human resource sex distribution of Ethiopia where, for instance, only 32% of nurses and 12% of health officers were females (Haileamlak, 2018).

Table 1.

Socio-Demographic Characteristics of Study Respondents, in Oromia, Ethiopia (N = 422).

Variable	Category	Frequency (F)	Percent (f = %)
Age	Younger than 30	115	27.3
	30–39	142	33.6
	40–49	122	28.9
	50–59	39	9.2
	60 and older	4	0.9
Gender	174	174	41.2
Gender	248	248	58.8
Educational level	Master’s	34	8.1
	Bachelor’s	263	62.3
	Diploma	125	29.6
Work experience in years	1–10 years	234	55.5
	11–20 years	151	35.8
	21–30 years	37	8.8

Of all respondents, 263 (f = 62.3%) had a bachelor’s degree as their highest level of education, and 125 (f = 29.6%) had a diploma in the healthcare profession. The Ethiopian healthcare system is very privileged to have more degree-prepared nurses than Kenya, where only 1.96% of nurses (n = 257; F = 5) were degree prepared (Chelagat, 2015).

More than half, 234 (f = 55.5%) of the health professionals had work experience of 10 years and less, and 151 (f = 35.8%) had 11 to 20 years of experience in their current postnatal care position.

It, therefore, seems postnatal care providers and coordinators in Ethiopia had the required experience and thus they have adequate as well as relevant clinical experience in postnatal care services (Haileamlak, 2018).

As shown in Figure 1, 249 (N = 422; f = 59.0%) of the study respondents were working in health centers, 151 (f = 36%) were working at district hospitals, and 20 (f = 5%) were working in the district health department. Only two (f = 0.5%) were working in the regional health department.

Figure 1.

Distribution of respondents by health facility type they were working.

Postnatal Care Practices in Ethiopia

Postnatal Care Room (N = 422)

Of all respondents, 238 (56.4%) reported that the room where postnatal care is rendered is separate, while 184 (43.6%) replied that there was no separate room for the postnatal care services. This result indicated a significant difference between Ethiopia and Kenya in the availability of separate postnatal care rooms whereas in Kenya, 78.82% (n = 255) of respondents indicated that postnatal mothers revealed postnatal care services in units specially designated for them (Chelagat, 2015).

Competency of the Postnatal Care Providers (N = 422)

Postnatal care providers must have the necessary competency to provide postnatal care as those who lack the competency can not provide quality and standardized postnatal care (Kim et al., 2020; Shorey et al., 2021). However, this study indicated, of all respondents, nearly one in three (33.9%) had the opinion that postnatal care providers lack the competency to provide quality postnatal care (refer to Table 2).

Table 2.

Competency of Postnatal Care Providers (N = 422).

Respondents	Are postnatal care providers competent	Frequency (F)	Percent (%)
All respondents (N = 422)	Yes	279	66.1
All respondents (N = 422)	No	143	33.9

Continuing Professional Education (N = 422)

Of all respondents, 262 (62.1%) participated in continuous professional education to ensure competency. Participation in professional development activities in this study proved to be lower compared to the Kenyan study that reported 89.53% of active participation in professional development (Chelagat, 2015). This is a significant concern that needs improvement.

Teamwork (N = 422)

As indicated by Mosadeghrad (2014), cooperation and teamwork are important components of high-quality healthcare services, including postnatal care. Teamwork supports the provision of efficient, effective, and quality postnatal care and promotes shared responsibility for patient care among the postnatal care team at different levels (Chelagat, 2015). The research findings in this study revealed that 362 (85.8%) reported that postnatal care providers work in a team.

Supportive Supervision (N = 422)

Supportive supervision increases healthcare providers’ professional skills and competencies and thus influences the care and emotional support rendered to the mothers during the postnatal period (Olajubu et al., 2020; Roets et al., 2018). In this study, 278 (65.9%) respondents experienced supportive supervision in postnatal care services.

Record Keeping (N = 422)

Three hundred sixty-one (=85.5%) respondents indicated that postnatal care services rendered to mothers must be recorded. Record-keeping in postnatal care services can be improved by implementing consistent, supportive supervision where the supervisor checks the gap in recording and reporting and provides support when needed (Olajubu et al., 2020).

The Utilization of Guidelines (N = 422)

Guidelines can assist postnatal care providers and coordinators to deliver more holistic postnatal care, and foster communication skills between mothers and postnatal care providers as described by the WHO (2014). In this study, despite the benefits of the utilization of guidelines, 111 (26.3%) respondents reported that they did not use guidelines related to postnatal care.

Budget (N = 422)

In many developing countries, it is a common problem that health facilities offering postnatal care lack adequate budgets for purchasing drugs and medication to be used for postnatal care (Macdonald et al., 2019). Congruently, in this study, 186 (44.1%) claimed that the budget allocated for postnatal care services is inadequate.

Cultural Beliefs (N = 422)

Evidences indicate that Cultural practices and norms do have an impact on the health of mothers and babies during the postnatal period (Hamal et al., 2020) and, therefore, must be assessed and addressed. Consistently, in this study, 316 (f = 75%) respondents believed that the cultural practices in the community have an impact on both the provision and reception of postnatal care (refer to Figure 2).

Figure 2.

Cultural practices impact on postnatal care in Ethiopia.

Community Involvement (N = 422)

This study revealed that one in three (32.0%) community leaders were not involved in the planning of postnatal care services (refer to Figure 3), even though health service programs run successfully when community members are involved (Babalola et al., 2017).

Figure 3.

Community involvement in postnatal care in Ethiopia.

Phase 2 of the Study

Development of an Action Plan

An action plan can be defined as a road map designed to lead to a required designation, such as the resolution of existing health problems (Skelton & Owen, 2016; WHO, 2015a). The action plan developed in this study aids in the integration of ideas and resources to strengthen procedures and processes, ensuring health workers and other stakeholders are focused on common goals, leading to improvements in the utilization and quality of postnatal care (Jafari et al., 2015; Skelton & Owen, 2016; WHO, 2015b).

Process of the Development of the Draft Action Plan

The findings from the analyzed data in Phase 1 of the study as well as available literature, were used in developing the draft action plan and were thus subject to modification during the validation process in Phase 3 of this study. To achieve each of the actions/methods, the responsible groups/person/s were also identified and made part of the action plan. Lastly, for the improvement of postnatal care in Ethiopia through the implementation of the action plan, the time frame for achieving those objectives/action statements was set and incorporated into the action plan (Jafari et al., 2015; Lorig et al., 2014).

Components of an Action Plan

Although there may be variations in the components of an action plan depending on its purpose and the scope of implementation, the action plan must contain the following components as described by Lubbe et al. (2014).

the goal, objectives, or strategy to which the activities pertain;

the type of activities or changes that will take place;

the responsible body to perform each activity; and

the time frame for carrying out those activities.

In the action plan, based on its components as well as the recommendations made by the respondents during Phase 1 of the study and the consulted literature, the action plan for implementation included six focus areas namely: (1) the problem: which is neglected postnatal care in Ethiopia; (2) Community needs; (3) Output; (4) Influential factors; (5) Strategies; and (6) Assumptions (refer to Table 4). As a component of the action plan, the community needs included issues such as (1) Policies and guidelines; (2) Human resources; (3) Financial resources; (4) Continuing professional education; (5) Effective monitoring; (6) Consistent evaluation; (7) Coordination of postnatal care; (8) Data management processes; (9) Community involvement; (10) Community surveillance; (11) Social and cultural practices; (12) Incentives for postnatal care providers; (13) Maternal waiting homes; (14) Effective communication; and (15) Cultural ceremonies. The strategies in the action plan included: (1) Capacity building; (2) Quality assurance; and (3) Supportive supervision.

Some of the issues under community needs and strategies are presented below.

Health Facility Infrastructure

Health service delivery depends on the availability of basic health infrastructure (Hamal et al., 2020). During Phase 1 of this study, the postnatal care providers and coordinators identified the inadequate health-related infrastructure in Ethiopia as a barrier to postnatal care services and they believed that strategies to improve infrastructure should be included in the action plan. The government of Ethiopia, therefore, must review the health facility infrastructural needs; particularly safe water and electricity supply, and allocate financial resources according to these established needs to improve postnatal care.

Road Infrastructure

The lack of sufficient roads that can be driven on in all weather conditions contributes to the inaccessibility of healthcare as villages, towns, and rural health facilities cannot be easily connected (Tiruneh et al., 2020). The availability of transportation systems (good roads) is an input that will contribute to improved access to health facilities that will improve postnatal care (Wilunda et al., 2015). Congruently, in this study, respondents indicated that the lack of roads contributed to the inaccessibility of transportation for the community and postnatal care utilizers and thus respondents recommended the need to improve the transportation system in Ethiopia.

Medical Resources

The respondents in Phase 1 of the study suggested the need to improve medical resources such as drugs and medical supplies) that are required for the provision of quality postnatal care. Unfortunately, health systems in developing countries face shortages of medical resources and equipment such as diagnostic types of equipment which negatively impact health service delivery including postnatal care (Bonfim et al., 2016). Congruently respondents of this study indicated that postnatal care is challenged by a shortage of medical equipment and they recommended the need to improve the availability of the medical equipment at all health facilities for postnatal care improvement.

The draft action plan for implementation was developed and sent to panelists for validation. The action plan includes the identified strategies, the action statements that can be seen as the objectives needed to be reached, the actions/methods to achieve the action statements, the possible persons responsible to achieve the required results, as well as the possible time frames needed for the implementation of the actions to achieve the action statements or the required result. The developed action plan was validated by experts in phase 3 of this study.

Phase 3 of the Study

During this phase of the study, the draft action plan for postnatal care improvement was validated using the Delphi technique. Eighteen purposively selected postnatal care coordinators working in different health system levels in Ethiopia participated in this phase of the study. All comments and recommendations that were provided by the Delphi panelists in each of the rounds were essential to improve the draft action plan until the action plan was validated.

Findings From Round 1 Delphi

In all rounds (1–3) of the Delphi process, all 18 invited panelists participated, thus a 100% response rate was achieved. Round 1 was completed in 3 weeks.

Biographical Data

As illustrated in Table 3, the participating panelists were from a diverse professional backgrounds and had at least a BSc degree. Concerning gender, 12 (f = 66.7%) Delphi panelists were males and six (f = 33.3%) were females.

Table 3.

Professional Background of the Delphi Panelists, Oromia, Ethiopia (N = 18).

Qualification	Occupation	n	f = %
Master’s of Public Health	Public health	2	11.1
MSc in Nursing	Nursing	3	16.7
MSC in maternity or midwifery	Midwifery	4	22.2
BSc in public health (health officer)	Health officer	2	11.1
BSc in Nursing	Nurse	2	11.1
BSc in midwifery	Midwife	5	27.8
Total		18	100

The responses of all 18 panelists were analyzed as described, and the findings were discussed under the headings (1) The problem, (2) Community needs, (3) Output, (4) Influential factors, (5) Strategies, and (6) Assumptions.

A consensus was reached for nearly all action statements/objectives. However, consensus was not reached for nearly all the time frames when the action plan is implemented. Hence based on the inputs from the panelists during Round 1, the validation instrument was amended and the new version was prepared for Round 2. For all items where consensus was reached, they were indicated as “consensus” in the validation instrument. The panelists were asked only to respond to the relevant items where consensus was not reached in the next round. The validation instrument was again loaded on the Google Forms online survey, as was the case in round 1. It was sent to the 18 panelists by sharing the recruitment letter with clear instructions on what is expected in the second round.

Findings From Round 2 Delphi

Based on the inputs from the panelists during Round 1, the validation instrument was amended and the new version was prepared for Round 2. All items where consensus was reached were indicated as “consensus” in the validation instrument. The panelists were asked only to respond to the relevant items where consensus was not reached.

The validation instrument was again loaded on the Google Forms online survey, as was the case in round 1. It was sent to the 18 panelists by sharing the recruitment letter with clear instructions on what is expected in the second round. In round 2, consensus was reached for all items except one, namely the time frame for establishing community surveillance.

Findings From Round 3 Delphi

Although consensus was reached in rounds 1 and 2 of the Delphi process, some amendments were made to the developed action plan. Accordingly, round 3 included two additional action statements namely, (1) action statement 34: Health facility infrastructure must be secured for improvement of postnatal care and (2) action statement 35: The provision of appropriate medical drugs and supplies. Therefore, the total number of action statements in round 3, increased to 39. The action plan for implementation and the embedded validation instrument were loaded on the Google Forms online survey. The panelist again received the recruitment letter with the link to give them access to the instructions and the validation instrument.

Validated Action Plan for Postnatal Care Improvement

As explained, the action plan for postnatal care improvement in Ethiopia was validated by analyzing the responses and recommendations by panelists during the three rounds of the Delphi technique. The final and validated action plan (refer to Table 4) for postnatal care improvement will have to be used as an addendum to ensure the quality of postnatal care in the Ethiopian context.

Table 4.

Finally, Validated Action Plan for Postnatal Care Improvement in Ethiopia.

Action statements	Actions /Methods	Responsible person/s	Time frame
THE PROBLEM
Postnatal care is a neglected aspect of health care in Ethiopia
COMMUNITY NEEDS
Action statement 1 Policies and guidelines aimed at ensuring the provision of comprehensive postnatal care services must be implemented.	1. Ensure that all health facilities have access to postnatal care guidelines and policies.2. Distribute an adequate number of guidelines and policies for all health facilities.3. Make sure that postnatal care is offered based on guidelines and policies at all health facilities.	A team of postnatal care service providers at district, regional, and national levels appointed by their co-workers.	Within 12 months after the action plan is developed.
Action statement 2 Human resources for the provision of quality postnatal care services must be ensured.	1. Conduct a staff workload indicator assessment at least twice a year to identify shortages.2. Recruit skilled and competent postnatal care providers to adhere to the WHO recommendation of the population-to-midwifery ratio of 23 midwives for every 10,100 women.3. Instill career growth opportunities for postnatal care providers working in rural health facilities.4. Negotiate with the finance department at the national level on incentives for postnatal care service providers working in rural areas of Ethiopia.5. Promote professional development training opportunities for postnatal care providers.6. Train postnatal care providers who meet the healthcare needs of postnatal mothers.	An appointed team of human resource managers at district, regional, and national levels (appointed by the heads of the health departments at the various levels)	Within 12 months after the development of the action plan.
Action statement 3 Financial resources for the provision of quality postnatal care services must be ensured.	1. Develop and implement an action plan to secure financial resources for the delivery of ordered supplies.2. Arrange annual meetings with postnatal care coordinators at different levels of the health system to secure financial resources.3. Develop and implement procedures to ensure accurate procurement to optimally utilize the available financial resources.	An ad hoc committee selected from the officials responsible for the postnatal service delivery budget at district, regional, and national levels (appointed by the health departments at the various levels).	Within 12 months after the development of the action plan.
Action statement 4 Continuing professional education must be strengthened to improve postnatal care	1. Develop an action plan for professional development training to ensure the participation of all postnatal care providers.2. One professional development training schedule opportunity per year must be compulsory for every postnatal care provider.3. Attain a record of postnatal care providers who attended continuing professional education to ensure compliance.	An appointed committee (appointed by the head of Oromia Regional Health Bureau and postnatal care coordinator at the National Ministry of Health) was selected from the in-service training coordinators at Oromia Regional Health Bureau and the Ministry of Health.	Within 9 months after the development of the action plan.
Action statement 5 Effective monitoring of postnatal care services is required	1. Conduct a quarterly inspection of the health facilities rendering postnatal care.2. Compile quarterly quality assurance reports for submission to the Ministry of Health.3. Identify gaps in the quality of postnatal care being rendered.4. Communicate all challenges detected to the appropriate managers.	An appointed team of program officers working at the district, regional and national levels (selected by their peers within the various levels).	Within 1 month after the development of the action plan.
Action statement 6 There should be a consistent evaluation of postnatal care services	1. Evaluate the quality of postnatal care services at least every 3 months.2. Improve postnatal care coordinators’ assessment skills through training programs.3. Share the quality assessment results and experiences with postnatal care coordinators at least once a year at a formal postnatal care summit.	An appointed team of program officers working at the district, regional and national levels (appointed by their peers at the various levels).	Within 12 months after the development of the action plan.
Action statement 7 The coordination of postnatal care services must be improved.	1. Enhance community involvement in postnatal care by increasing community participation.2. Provide health education to the community to increase awareness regarding the importance of postnatal care.3. Facilitate communication networks among postnatal care coordinators and the different stakeholders.4. Implement the use of mobile phones and social media to provide information on the importance of postnatal care.	An appointed team of postnatal care program officers working at the district, regional and national levels (appointed by their direct managers at the various levels).	Immediately after the development of the action plan.
Action statement 8 Data management processes, such as recording and reporting of postnatal care services, must be improved.	1. Provide technical support to postnatal care providers and coordinators to record postnatal care data.2. Arrange ICT training to improve the technical skills of postnatal care providers and coordinators.3. Implement the use of ICT to manage records, medical drugs, and information sharing.4. Implement a timely reporting system for postnatal care service delivery at all health facilities offering postnatal care.	An appointed team of health management information heads working at health facilities, district, regional and national levels (appointed by the heads of the postnatal care coordinating offices at the different levels).	Within 1 month after the development of the action plan.
Action statement 9 Community involvement in postnatal care services must be improved.	1. Improve the postnatal care knowledge of the community through social media.2. Involve community leaders in the development of educational material.3. Select community members to participate in communicating educational material and messages to the community.4. Involve the community in planning postnatal care activities.	An appointed team of postnatal care program officers working at the district, regional and national levels (appointed by heads of the postnatal coordinating offices at the various levels).	Within 6 months after the development of the action plan.
Action statement 10 Establish community surveillance of maternal and neonatal deaths.	1. Conduct annual surveillance on maternal and neonatal deaths.2. Develop an effective reporting system for maternal and neonatal deaths.	An appointed team of postnatal care program officers working at the district, regional and national levels (appointed by heads of the postnatal coordinating offices at the various levels).	Within 12 months after the development of the action plan.
Action statement 11 Identify and address social and cultural practices, myths, and misconceptions about postnatal care.	1. Assess the cultural practices in the community that impact postnatal care services.2. Conduct IEC for increasing awareness and knowledge of cultural misconceptions.3. Involve the community in identifying the cultural issues that impact postnatal care by facilitating meetings between the healthcare workers and the community.4. Involve the community in addressing the cultural issues that impact postnatal care by facilitating community meetings.	An ad hoc committee of postnatal care program officers (at the district level) appointed by their peers as well as appointed community members selected by the district postnatal coordinating offices.	Within 6 months after the development of the action plan.
Action statement 12 Provide incentives for postnatal care providers.	1. Provide a certificate at an award ceremony for those identified to be the best performers.2. Instill career opportunities for those with high-performance appraisal results.3. Allocate additional professional development opportunities for those with high-performance appraisal results	An ad hoc committee of program officers working at regional health departments (appointed by the head of the regional health department) to liaise with the national health department for the implementation of the incentives	Within 12 months after the development of the action plan.
Action statement 13 Maternal waiting homes must be available at all health facilities.	1. Provide areas that can serve as maternal waiting homes at all health facilities.2. Equip the maternal waiting homes with the necessary infrastructure such as electricity, water supply, kitchens, and adequate rooms.3. Ensure that maternal waiting homes comply with culture-congruent requirements by involving the community in the development thereof.	Appointed postnatal care program officers working at the district, regional and national levels (appointed by the postnatal care coordinating offices) at the various levels as well as selected community members appointed by the directors of the health facilities.	Within 12 months after the development of the action plan.
Action statement 14 Ensure effective communication for ambulance services and other postnatal care issues.	1. Communicate the contact details of all available ambulance services to mothers via social media and printed communication.2. Develop an effective communication system to ensure ambulance service accessibility.3. Ensure the availability of ambulance services at all health facilities.	An ad hoc committee consisting of ambulance drivers, community leaders (selected by the directors of the health facilities), as well as postnatal care program officers working at the health facilities (appointed by their peers and the directors of the health facilities).	Within 1 month after the development of the action plan.
Action statement 15 Cultural ceremonies should be practiced at health facilities to motivate mothers to utilize institutional delivery and postnatal care.	1. Develop a policy that makes provision for cultural ceremonies in health facilities.2. Allow mothers and their families to practice their cultural ceremonies.3. Have maternal waiting homes at all health facilities rendering postnatal care.4. Equip the health facilities with the necessary infrastructure such as electricity, water supply, and adequate rooms to allow for the practice of their culture.	An ad hoc committee consisting of selected community and religious leaders, as well as the program officers working at the district level (appointed by the heads of district health departments) to liaise with the regional and national health departments.	Within 3 months after the development of the action plan.
OUTPUT
Action statement 16 The implementation of a contextualized framework for postnatal care will contribute to improvement in postnatal care follow-up visits at the community level.
Action statement 17 Implementation of a framework to improve postnatal care will contribute to accurately written reports on the postnatal care services at different levels of the health system.
Action statement 18 The quality of postnatal care services offered to postnatal mothers and their babies at health facilities in Ethiopia needs to be improved through the implementation of a contextualized framework.
Action statement 19 The implementation of the framework will enhance partnerships forming in matters regarding the provision of postnatal care services.
INFLUENTIAL FACTORS
Action statement 20 The Ethiopian government is committed to the attainment of the health sector transformation plan which can contribute to improvements in postnatal care.
Action statement 21 Good governance in Ethiopia is a contributing factor to the implementation of the contextualized framework and thus the improvement in postnatal care.
Action statement 22 The Ethiopian government’s political will must facilitate the implementation of the contextualized framework.
Action statement 23 Establish community health units for postnatal care improvement.	1. Strengthen the community health workers’ skills through training to provide preventive services2. Improve the health extension workers’ competency through continuing professional development to provide home-based postnatal care	An appointed team of postnatal care coordinators at district levels (appointed by the head of health offices)
Action statement 24 The FMOH should improve the budget allocated for postnatal care to minimize the budget constraints for postnatal care services in Ethiopia
Action statement 25 Ensure partner/donor support for postnatal care.	1. Invite local and national partners to participate in technical and financial support for postnatal care improvement.2. Negotiate partnerships with donors.3. Use the technical and financial support from the partners for postnatal care improvements.	An ad hoc committee consisting of the directors of health facilities and postnatal care program officers working at the district level (appointed by heads of the district postnatal care coordinating offices).	Immediately after the development of the action plan.
Action statement 26 Male engagement in aspects of postnatal care must be improved.	1. Increase males’ awareness of the benefits of postnatal care through mass media.2. Improve male involvement through discussions with community leaders.3. Improve male involvement through discussions with religious leaders.	An ad hoc committee consisting of community and religious leaders appointed by district postnatal care coordinating offices, as well as postnatal care coordinators at district and regional levels (appointed by the various health departments).	Within 6 months after the development of the action plan.
Action statement 27 Address the socio-economic factors that influence postnatal care.	1. Encourage women to postpone marriage until 18 years.2. Implement strategies to prevent teenage pregnancies.3. Advocate for the improvement of employment opportunities for women (job opportunities).	An ad hoc committee consisting of postnatal care coordinators, the women’s development army, as well as community leaders (selected by the district health department).	Within 2 years after the development of the action plan.
Action statement 28 Improve the literacy levels of postnatal mothers.	1. Encourage pregnant and postnatal mothers to improve their level of education through mass media.2. Involve the community in motivating pregnant and postnatal mothers to attain an education.3. Involve religious leaders in motivating pregnant and postnatal mothers to improve their level of education.	An appointed team of community and religious leaders (appointed by the head of the district postnatal care coordinating offices) and district and regional education offices program officers (appointed by the heads of the various education offices).	Within 3 years after the development of the action plan.
Action statement 29 Address the religious factors that influence postnatal care service utilization.	1. Conduct IEC to increase awareness and knowledge on religious factors that impact postnatal care utilization.2. Improve women’s and the community’s knowledge through health education to overcome religious influences.	An ad hoc committee consisting of community and religious leaders, as well as district postnatal care program officers (appointed by the head of the district postnatal care coordinating offices).	Within 12 months after the development of the action plan.
Action statement 30 Poor access to postnatal care services must be improved.	1. Increase the number of health facilities.2. Renovate the existing health facilities.Improve transportation services for easy access to health facilities.	An appointed team of postnatal care program officers working at the district, regional and national levels (appointed by the heads of postnatal coordinating offices at the various levels) to liaise with the federal (national) Ministry of Health.	Within 1 year after the development of the action plan.
STRATEGIES
Action statement 31 Capacity building for postnatal care providers and coordinators is an important strategy for postnatal care improvement.	1. Ensure the implementation of continuous professional education.2. Instill an attendance register of postnatal care providers for professional development training at least once a year.	An ad hoc committee from in-service training coordinators at the regional health bureau and Ministry of Health (appointed by heads of the regional health bureau and the National Ministry of Health).	Within 12 months after the development of the action plan.
Action statement 32 There should be quality assurance mechanisms for postnatal care services.	1. Implement standard operating procedures when rendering postnatal care.2. Provide quality counseling services to postnatal mothers.3. Provide compassionate and respectful care to enhance postnatal mothers’ satisfaction.4. Provide effective “whistle-blow” opportunities to complain about the quality of care rendered.	An appointed team of program officers working at district, regional, and national levels (appointed by the head of postnatal care coordinating offices at the various levels).	Within 12 months after the development of the action plan.
Action statement 33 Supportive supervision should be implemented at all health facilities.	1. Provide training to improve supervision skills for postnatal care coordinators.2. Conduct supportive supervision of postnatal care services at least quarterly.Provide technical and financial support to postnatal care coordinators to conduct supportive supervision.	An appointed team of postnatal care service program officers working at the district, regional and national levels (appointed by the head of postnatal care coordinating offices at the various levels).	Within 6 months after the development of the action plan.
Action statement 34 Health facility infrastructure must be secured for the improvement of postnatal care.	1. Prepare an audit report on the quality and availability of infrastructure.2. Renovate the existing infrastructure of facilities.3. Submit the audit reports to the Ministry of Health through the district health department.4. Prepare a separate and adequate room/space for postnatal care at all health facilities.5. Provide all health facilities with safe water and functioning hydroelectric power.5. Link all health facilities with a 24-hour functional referral system.	An appointed team of postnatal care program officers working at the district, regional and national levels (appointed by the head of postnatal care coordinating offices at the various levels).	Within 2 years after the development of the action plan.
Action statement 35 Appropriate medical drugs and supplies for postnatal services must be ensured.	1. Ensure procurement and availability of all the necessary drugs for the provision of postnatal care.2. Enhance the postnatal care providers’ skills in maintaining the stock balance on essential drugs.3. Establish and sustain strong partnerships with national and international medical drug producers.	An appointed team of postnatal care program officers working at the district, regional and national levels (appointed by the heads of postnatal care coordinating offices at the various levels).	Within 1 year after the development of the action plan.
ASSUMPTIONS
Action statement 36 The Ethiopian government will be efficient in coordinating postnatal care services.
Action statement 37 Postnatal care services included in the government policy should be free.
Action statement 38 The Ethiopian government will embrace the implementation of maternal and neonatal health services.
Action statement 39 The health extension program must be sustained for the implementation of the contextualized framework in Ethiopia.

In the validated action plan, each of the action statements has its actions/methods to achieve the action statements, the responsible person/s, as well as the time frame in which those actions should be taken. However, for some action statements, as indicated in Table 4, there were no actions/methods, responsible person/s, and time frames as those items were only incorporated to assess the level of the panelists’ agreement to validate the action plan for postnatal care improvement in the Ethiopia context.

Strengths and Limitations

As strengths, the study used mixed research method that assessed different aspects of the problem. How ever it was a limitation that, in Phase 1, due to budget and other resource constraints, only selected health facilities (health centers and hospitals) were included and there may be differences in views and opinions among postnatal care providers from unselected health facilities due to possible differences in access to resources for postnatal care.

Conclusion and Recommendation

This sequential mixed-method study was followed to develop and validate an action plan for postnatal care improvement in Ethiopia. An action plan to enhance the improvement of postnatal care in Ethiopia was developed. The inputs and recommendations from the panelists during the 3 rounds of Delphi as well as the available literature were used to develop the final action plan to improve postnatal care.

The study concluded that the developed action plan can contribute to the improvement of postnatal care in Ethiopia. Therefore, the Ethiopian federal ministry of Health (FMOH) should take the lead and responsibility in ensuring the implementation of the action plan with the involvement of stakeholders and partners.

Footnotes

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

Funding

The author received no financial support for the research,authorship,and/or publication of this article.

ORCID iD

Elias Teferi Bala

Data Availability Statement

Data for this study is available based on the request from concerned bodies.

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An Action Plan to Improve Postnatal Care in Ethiopia: A Mixed Methods Research