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Background: Amid efforts to improve the quality of care for women and neonates during childbirth, there is growing interest in the experience of care, including respectful care practices. However, there is little research on the prevalence of practices that might constitute mistreatment of neonates. This study aims to describe the care received by neonates up to 2 h after birth in a sample of three countries in west Africa. Methods: Data from this multicountry, facility-based, observational study were collected on 15 neonatal care practices across nine facilities in Ghana, Guinea, and Nigeria, as part of WHO’s wider multicountry study on how women are treated during childbirth. Women were eligible if they were admitted to the participating health facilities for childbirth, in early established labour or active labour, aged 15 years or older, and provided written informed consent on behalf of themselves and their neonate. All labour observations were continuous, one-to-one observations of women and neonates by independent data collectors. Descriptive statistics and multivariate logistic regressions were used to examine associations between these neonatal care practices, maternal and neonate characteristics, and maternal mistreatment. Early neonate deaths, stillbirths, and higher order multiple births were excluded from analysis. Findings: Data collection took place from Sept 19, 2016, to Feb 26, 2017, in Nigeria; from Aug 1, 2017, to Jan 18, 2018, in Ghana; and from July 1 to Oct 30, 2017, in Guinea. We included data for 362 women–neonate dyads (356 [98%] with available data for neonatal care practices) in Nigeria, 760 (749 [99%]) in Ghana, and 558 (522 [94%]) in Guinea. Delayed cord clamping was done for most neonates (1493 [91·8%] of 1627); other practices, such as skin-to-skin contact, were less commonly done (1048 [64·4%]). During the first 2 h after birth, separation of the mother and neonate occurred in 844 (51·9%) of 1627 cases; and was more common for mothers who were single (adjusted odds ratio [AOR; adjusting for country, maternal age, education, marital status, neonate weight at birth, and neonate sex] 1·8, 95% CI 1·3–2·6) than those who were married or cohabiting. Lack of maternal education was associated with increased likelihood of neonates not receiving recommended breastfeeding practices. Neonates with a low birthweight (<2·5 kg) were more likely (1·7, 1·1–2·8) to not begin breastfeeding on demand than full weight neonates. When women experienced physical abuse from providers within 1 h before childbirth, their neonates were more likely to be slapped (AOR 1·9, 1·1–3·9). Interpretation: A high proportion of neonates did not receive recommended care practices, and some received practices that might constitute mistreatment. Further research is needed on understanding and measuring mistreatment to improve care, including respectful care, for mothers and neonates. Funding: US Agency for International Development, and the UNDP/UN Population Fund/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO.
This multicountry, facility-based, observational study is a secondary analysis of a subset of data from the WHO multicountry study on how women are treated during facility-based childbirth in Nigeria, Ghana, Guinea, and Myanmar.15 The wider study included a mixed-methods systematic review,5 formative primary qualitative research in Nigeria, Ghana, Guinea, and Myanmar,23, 24, 25, 26, 27, 28 and a measurement phase that developed and validated two tools to measure the burden of mistreatment of women during childbirth across the four countries.29 In each country, three public health facilities were selected based on the following inclusion criteria (1) facilities that were not included in the formative phase of research, (2) secondary-level facility or higher, (3) 200 or more births per month, and (4) a well-defined community catchment area. Data collection took place from Sept 19, 2016, to Feb 26, 2017, in Nigeria; from Aug 1, 2017, to Jan 18, 2018, in Ghana; from July 1 to Oct 30, 2017, in Guinea; and from June 26 to Sept 5, 2017, in Myanmar. The methodological development of the measurement tools,29 detailed study methods, and results of the primary analysis are described in detail elsewhere.15 This analysis used data collected across three countries (Ghana, Guinea, and Nigeria) from the labour observation tool, because labour observations were not done in Myanmar. Women were eligible for labour observations if they were admitted to the participating health facilities for childbirth in early established labour or active labour, aged 15 years or older, willing and able to participate, and provided written informed consent on behalf of themselves and the neonate. Institutional permission for recruitment and observation was obtained from each site; consent was not sought from providers. This study was approved by the WHO Ethical Review Committee (A65880) and WHO Review Panel on Research Projects. In Guinea this study was approved by le comité national d'éthique pour la recherche en santé; in Nigeria by the Federal Capital Territory Health Research Ethics Committee, Research Ethical Review Committee, Oyo State, and State Health Research Ethics Committee of Ondo State; in Ghana by the Ethical Review Committee of the Ghana Health Service, and the Ethical and Protocol Review Committee of the College of Health Sciences, University of Ghana; and in Myanmar by the Ethics Review Committee and Department of Medical Research. The labour observation tool is publicly available29 and is comprised of an admission form, an incidents of mistreatment report form, and a childbirth, interventions, and discharge form that includes a subsection on neonatal practices.29 The tool is organised according to the type of mistreatment experienced by women during childbirth.5 All labour observations were continuous, one-to-one observations of women and their neonates by independent data collectors. Once a woman gave consent (inclusive of her neonate) and was enrolled, observations continued throughout labour, childbirth, and until 2 h after birth. The tool development and validation process has been described elsewhere.29 Data were collected using digital, tablet-based tools with built-in quality checks and validation rules (BLU Studio XL2, Android, BLU Products; Miami, FL, USA). Data were submitted securely to a central database (WHO; Geneva, Switzerland) using a 3G cellular connection or wireless internet. Consistency checks for screening logs, recruitment, and data were done weekly by WHO and country research teams; inconsistencies were resolved during data collection. For this analysis, we used neonate data collected during the 2 h period after birth (from the childbirth interventions and discharge form) and maternal data collected during the entire study.15 Data on 15 observed neonatal practices were collected and measured once at the end of the 2 h observation period. For standardised comparison of findings across countries, this analysis was restricted to women who had a vaginal birth only and, in the case of multiple births, only the first-born neonate. Maternal sociodemographic, obstetric, and neonatal characteristics were aggregated and presented as proportion of women who had a vaginal birth and by country. The χ2 test was used to compare differences of maternal and neonatal characteristics across the three countries (Nigeria, Ghana, and Guinea). Descriptive analyses were done to explore 15 observed neonatal practices, including recommended practices and practices that might constitute mistreatment across the three countries. For this analysis, we excluded early neonatal deaths and stillbirths (fresh or macerated). The χ2 test was used to compare differences of neonatal care practices across the three countries. We evaluated factors potentially associated with the provision of the four practices that WHO recommends as routine care for all neonates19 and breastfeeding:4 immediate skin-to-skin contact with mother, non-separation of the neonate from the mother after birth, breastfeeding within 30 min after birth, and breastfeeding on neonate demand. Multivariable logistic regression models were fitted to evaluate whether maternal age, education, marital status, neonate weight at birth, and neonate sex were associated with the occurrence of these neonatal practices. Mistreatment of women by health care providers, particularly physical abuse, is highly prevalent in the 1 h before childbirth;15 therefore, we explored the associations, using multivariable logistic regression, between women who experienced physical abuse 1 h before childbirth and observations related to the physical handling of the neonate, such as slapping of the neonate and holding the neonate by the leg or upside down. The multivariable model included potential associated factors—ie, country, maternal age, maternal education, marital status, neonate weight at birth, and neonate sex. Data analysis was done using SAS, version 9.4. The funders of the study were involved in developing the research question and in investigator meetings, but had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.
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