Newborn care practices at home and in health facilities in 4 regions of Ethiopia

Background: Ethiopia is one of the ten countries with the highest number of neonatal deaths globally, and only 1 in 10 women deliver with a skilled attendant. Promotion of essential newborn care practices is one strategy for improving newborn health outcomes that can be delivered in communities as well as facilities. This article describes newborn care practices reported by recently-delivered women (RDWs) in four regions of Ethiopia.Methods: We conducted a household survey with two-stage cluster sampling to assess newborn care practices among women who delivered a live baby in the period 1 to 7 months prior to data collection.Results: The majority of women made one antenatal care (ANC) visit to a health facility, although less than half made four or more visits and women were most likely to deliver their babies at home. About one-fifth of RDWs in this survey had contact with Health Extension Workers (HEWS) during ANC, but nurse/midwives were the most common providers, and few women had postnatal contact with any health provider. Common beneficial newborn care practices included exclusive breastfeeding (87.6%), wrapping the baby before delivery of the placenta (82.3%), and dry cord care (65.2%). Practices contrary to WHO recommendations that were reported in this population of recent mothers include bathing during the first 24 hours of life (74.7%), application of butter and other substances to the cord (19.9%), and discarding of colostrum milk (44.5%). The results suggest that there are not large differences for most essential newborn care indicators between facility and home deliveries, with the exception of delayed bathing and skin-to-skin care.Conclusions: Improving newborn care and newborn health outcomes in Ethiopia will likely require a multifaceted approach. Given low facility delivery rates, community-based promotion of preventive newborn care practices, which has been effective in other settings, is an important strategy. For this strategy to be successful, the coverage of counseling delivered by HEWs and other community volunteers should be increased. © 2013 Callaghan-Koru et al.; licensee BioMed Central Ltd. The Federal Democratic Republic of Ethiopia is the second most populous country in Africa with a population of 85 million. The population is growing at a rate of 2.6% per year [19], and the total fertility rate is estimated at 4.8 children per woman [17]. According to the 2007 census, 84% of the population lives in rural areas where the primary occupation is farming, making Ethiopia one of the least urbanized countries in the world [20]. Ethiopia also has the tenth largest land area in Africa, with diverse geography and peoples and over 80 spoken languages. This study includes the regions of Oromia, Tigray, Amhara, and Southern Nations, Nationalities, and People (SNPP), which are supported by the United States Agency for International Development’s Maternal and Child Health Integrated Program in a pilot implementation of community-based newborn and kangaroo mother care promoted by Health Extension Workers. These four regions were chosen for the pilot program because they account for more than 85 percent of the country’s total population [19] and represent the diverse cultural and linguistic differences of the many ethnic groups in the country. Table  1 presents demographic and health indicators for these four regions. Characteristics of study regions Sources: 2011 DHS Survey; *2007 National Census. The Ethiopian Federal Ministry of Health provides primary health services free of charge through primary hospitals (1 per 60,000-100,000 population), health centers (1 per 15,000- 25,000) and health posts (1 per 5,000 people). In 2003, in order to extend primary care access to rural areas, the government established a new cadre of workers, known as Health Extension Workers (HEWs), to provide basic health care from rural health posts [21]. The package of services provided by health extension workers includes environmental health promotion, family planning, immunization, and maternal and child health services [21]. HEWs are typically young women with at least a grade 10 education and receive one-year of training before deployment to a Health Post in their community [22]. More than 34,000 HEWs currently provide basic health services from 15,666 health posts across the country. Supporting the HEWs is the volunteer Health Development Army, composed of approximately 1 household with a model woman networked with 5 other households, who mobilize the community and provide health education. Despite Ethiopia’s achievements to improve access to maternal, newborn, and child health services, accelerated progress is needed for the country to achieve Millennium Development Goal 4 [23], particularly in the area of newborn health. Currently 1 in every 27 Ethiopian children dies within his or her first month of life [7]. Nationally, neonatal deaths account for 42% of under-five deaths [17] and the primary causes for newborn death include birth asphyxia (30%), sepsis (24%), prematurity (23%), and pneumonia (8%) [3]. The neonatal mortality rates in the four regions included in this study range between 38 per 1,000 in SNNP to 54 per 1,000 live births in Amharra (Table  1). Routine health services for mothers and newborns are severely underutilized across Ethiopia. According to the DHS 2010, only 34% of women receive any antenatal care from a skilled provider, 10% of births take place at a health facility, and 7% of women receive a postnatal check up within the first two days of birth [17]. Reasons reported for low utilization of maternal health services in Ethiopia include lack of perceived need, distance to services, costs of services, negative experiences with or perceptions of quality of care at facilities, and preference for traditional birthing practices [24,25]. This article provides the results from a cross-sectional household survey of newborn care practices conducted to establish a baseline for a study to assess the feasibility of recently delivered women (RDWs) adopting kangaroo mother care (KMC) when promoted by HEWs and other health service providers. The study site included the catchment areas of 10 health centers in four regions—Tigray, Oromiya, Amhara, and SNNPR—that are participating in the pilot. Facility-based KMC was established at these ten health centers and facility staff received essential newborn care training prior to the baseline survey. However, the survey took place before the training of Health Extension Workers on community-level newborn care and kangaroo mother care promotion. We sampled 30 census enumeration areas (EA) from the catchment areas of the 10 health centers with probability proportional to size. Within each sampled EA, all households were screened in order to identify eligible women based on the criteria of delivering a live born child within 1 to 7 months prior to the survey. A sample size of 215 women was calculated to detect a 20-percentage point increase in the proportion of recent mothers who received the antenatal and postnatal services from the HEWs; to allow for up to 10% refusals, we targeted enrolling 240 women, or eight women per cluster. If more than eight eligible women were present in a cluster, the women were randomly chosen using a random number table. In six EAs fewer than eight women were found to be eligible, and other EAs were oversampled accordingly. A standard questionnaire developed by the Saving Newborn Lives Program was adapted for this survey (see Additional file 1). The questionnaire includes modules on respondent and household characteristics, antenatal care, birth preparedness, delivery and immediate newborn care, nutrition, postnatal care for mother and baby, neonatal illness and care seeking and has been field tested and used in previous studies in Ethiopia by Save the Children. Data were collected between January 4 and 27, 2012, by six teams of two to four interviewers and one supervisor. All personnel were skilled data collectors with previous experience on Demographic and Health Surveys. Prior to the start of data collection, a five-day training was provided to the data collectors and supervisors to orient the teams to the study objectives and ensure that they had mastered the research protocol and instrument. Following the household screening and selection procedures, interviewers visited each selected woman at her home to administer the survey. If a selected woman was not at home on the first attempt to visit her, two additional attempts were made before another participant was selected in her place. Informed consent was obtained from each household for screening and from each sampled woman before proceeding with the survey questions. Completed questionnaires were collected by supervisors in the field and transported to Addis Ababa for data entry. Double data entry was completed using a Microsoft Access database created for this survey. Two separate data clerks entered each form into a separate Access file. Discrepancies were identified and reconciled through reference to the original survey form. Additional data entry inconsistencies found during data exploration and analysis were recorded in an analysis log and corrected, when possible, by going back to the survey forms. Of the original 224 cases included in the data set, six were excluded from analysis. Three were excluded because the case was a twin and the survey had already been completed for the first-born twin. In three other cases, the child was less than 28 days old at the time of the survey and therefore was not eligible according to the predetermined criteria. A total of 218 cases were included in the analysis. Key indicators were calculated for each of the survey modules using Stata 11 [26]. Stratified analyses by place of delivery were also calculated for newborn care indicators, and differences were tested for statistical significance using the chi-squared test. Sampling weights were calculated for clusters as the inverse of the proportion of eligible RDWs in that cluster selected for the survey, to account for the lower than expected sample in some clusters and oversampling in others. Confidence intervals and statistical tests were conducted using robust standard errors to adjust for survey design [27]. This study was approved by the Institutional Review Boards at the Johns Hopkins Bloomberg School of Public Health (IRB No. 3542) and the Ethiopia Health and Nutrition Research Institute (SERO 72-2-2011).