Poor newborn care practices – a population based survey in eastern Uganda

BMC Pregnancy and Childbirth, Volume 10, Year 2010

Interpretação

Background: Four million neonatal deaths are estimated to occur each year and almost all in low income countries, especially among the poorest. There is a paucity of data on newborn health from sub-Saharan Africa and few studies have assessed inequity in uptake of newborn care practices. We assessed socioeconomic differences in use of newborn care practices in order to inform policy and programming in Uganda.Methods: All mothers with infants aged 1-4 months (n = 414) in a Demographic Surveillance Site were interviewed. Households were stratified into quintiles of socioeconomic status (SES). Three composite outcomes (good neonatal feeding, good cord care, and optimal thermal care) were created by combining related individual practices from a list of twelve antenatal/essential newborn care practices. Multiple logistic regression analysis was used to identify determinants of each dichotomised composite outcome.Results: There were low levels of coverage of newborn care practices among both the poorest and the least poor. SES and place of birth were not associated with any of the composite newborn care practices. Of newborns, 46% had a facility delivery and only 38% were judged to have had good cord care, 42% optimal thermal care, and 57% were considered to have had adequate neonatal feeding. Mothers were putting powder on the cord; using a bottle to feed the baby; and mixing/replacing breast milk with various substitutes. Multiparous mothers were less likely to have safe cord practices (OR 0.5, CI 0.3 – 0.9) as were mothers whose labour began at night (OR 0.6, CI 0.4 – 0.9).Conclusion: Newborn care practices in this setting are low and do not differ much by socioeconomic group. Despite being established policy, most neonatal interventions are not reaching newborns, suggesting a “policy-to-practice gap”. To improve newborn survival, newborn care should be integrated into the current maternal and child interventions, and should be implemented at both community and health facility level as part of a universal coverage strategy. © 2010 Waiswa et al; licensee BioMed Central Ltd. The study was conducted in the Makerere University-operated Iganga-Mayuge Demographic Surveillance Site (DSS) located in eastern Uganda, about 120 km east of the capital Kampala. The Basoga contribute about 10% of the population of Uganda, but their practices are similar to those of other Bantu ethnic groups who are the majority in Uganda. Eighty percent of the population are peasants and live on less than US$1 a day. An estimated 49% of women and 68% of men are literate (Iganga District Local Government 2008). Traditional birth attendants (TBAs) are significant actors in the provision of antenatal and delivery care in the district. At the time of the study, there were no specific interventions promoted to target the newborn, either at facility or community level. About 30% of the DSS population lives in peri-urban settings with relatively better access to health care compared to their rural counterparts. The DSS has a population of about 67,200 people in 65 villages, 18 parishes and 12,000 households. The household and community structures have been mapped using the Global Positioning System. Over forty locally recruited field assistants whose minimum education is upper secondary school level collect data from each household every fourth month and are supervised by a group of DSS staff from a central office. Village-based demographic scouts notify DSS staff of all deaths and births in the area as they occur on a continuous basis. The DSS area has 13 health facilities of which ten are government facilities including the district hospital, the other three being non-Governmental organisation facilities. The area is also served by over 120 pharmacies and private clinics. The neonatal and post-neonatal mortality rates in the DSS are estimated at 22.3 and 55.2 per 1000 live births, which compares very well with estimates for the entire region as reported in the national demographic health survey (24 and 50 per 1000 live births) [8]. This population-based cross-sectional study represents socio-demographic, SES, and antenatal and newborn care practices among Ugandan women with a baby aged 1-4 months (n = 414). Socio-demographic and household SES information were collected in a separate survey a year earlier. Socio-demographic information, as collected from the DSS, included age, level of education, occupation, religion, tribe, birth order, and sex of the reference child. Household SES is represented by household assets. The DSS field assistants underwent a three day training to use the survey tool which had been translated into Lusoga, the local language in the area. The training included piloting the tool among 25 mothers attending a postnatal clinic at the local hospital. The survey was conducted from March to August 2007. Mothers who had had a stillbirth (data not available) or a neonatal death (64 neonates) were not interviewed for this study. Data collected in this study included information about antenatal care (ANC) practices (attendance, place of attendance, number of visits made, HIV testing, birth preparedness, use of drugs to prevent malaria in pregnancy, and provider of ANC) and delivery (place, time of labour onset and type of attendant at delivery). Women were also asked about their experiences with ENC practices, including type of instrument used to cut the cord, type of material used to tie the cord, when the newborn was first dried and wrapped, length of time before the newborn was bathed the first time, whether any pre-lacteal feeds were given, length of time (hours/days) before breastfeeding was first initiated, and whether the baby was exclusively breastfed during the first month of life. The quality assurance of data was through daily assessment via questionnaires filled-in by a supervisor; in cases of error or incompleteness of data, corrective measures were implemented immediately. Data were entered using FoxPro and cleaned, linked with the DSS database, and then transferred to STATA, version 10, for analysis. For SES, we used the same group of context-specific assets used by the Uganda Bureau of Statistics. These items were screened for relevance, and reliability testing was done using Cronbach’s alpha [12]. The final list included the number of sleeping rooms, type of floor material, type of roof material, wall material, fuel used for cooking and source of light. Other variables were households having or not having the following items: a radio, a sewing machine, an electric flat iron, type of bed, charcoal flat iron, a bed net, kerosene lamp, kerosene stove, car, tea table, refrigerator, television set, sound stereo, telephone, mattress, wheel barrow, cell phone and camera. These gave a Cronbach’s alpha of 0.848. Principal component analysis (PCA) was performed and the first principal component was scored to create an asset index that was used to group all households in the DSS into wealth quintiles [13]. Using the following twelve ANC/ENC practices, we calculated the mean and median number of practices accessed by the mother/newborn: ANC, tetanus toxoid, antimalarial use during pregnancy, HIV test, and insecticide treated net (ITN) use, anemia drugs, clean birth, facility delivery, safe cord care, optimal thermal care, good breastfeeding, and ITN after birth. The following composite outcome variables were then created: (i) Good cord care (defined as use of a clean cutting instrument to cut the umbilical cord plus clean thread to tie the cord plus no substance applied to the cord); (ii) Optimal thermal care (defined as baby put skin-to-skin at birth or wrapped at birth plus first bath after 6 or more hours); and (iii) Good neonatal breastfeeding (defined as initiating breastfeeding within the first one hour after birth plus baby given no supplements at all in the first month of life). These composite variables were then dichotomised to Yes (all practices present) or No (one or more practices missing). The data were then subjected to standard descriptive analysis. Chi-square statistics were performed to compare the levels of each of the dependent variables with the explanatory variables. A multiple logistic regression model was constructed for each dichotomised outcome variable using all of the explanatory variables which were significant at bivariate analysis at a p-value of 0.05 or less after confirming absence of multi-colleneraity between the independent variables. The study was approved following ethical review by the Makerere University School of Public Health Institutional Review Board. As per the DSS routines for non-intrusive research verbal consent was sought from each mother after reading to her about and adequately explaining the purpose of the study. Participants were told that they were free not to participate or to withdraw during any stage of the interview. In addition, field assistants were trained to refer sick mothers/newborn babies with problems to the nearby government health facilities where treatment is provided free of charge.

AI Digest

Study Justification:

– Four million neonatal deaths occur each year, mostly in low-income countries, with a lack of data on newborn health from sub-Saharan Africa.
– This study aimed to assess socioeconomic differences in the use of newborn care practices in order to inform policy and programming in Uganda.

Study Highlights:

– The study was conducted in the Makerere University-operated Iganga-Mayuge Demographic Surveillance Site in eastern Uganda.
– The study included 414 mothers with infants aged 1-4 months.
– Three composite outcomes were created: good neonatal feeding, good cord care, and optimal thermal care.
– Low levels of coverage of newborn care practices were found among both the poorest and the least poor.
– Socioeconomic status and place of birth were not associated with any of the composite newborn care practices.
– Only 46% of newborns had a facility delivery, 38% had good cord care, 42% had optimal thermal care, and 57% had adequate neonatal feeding.
– Unsafe practices such as using powder on the cord, using a bottle to feed the baby, and mixing/replacing breast milk with substitutes were observed.
– Multiparous mothers and mothers whose labor began at night were less likely to have safe cord practices.

Recommendations:

– Newborn care should be integrated into current maternal and child interventions.
– Implementation of newborn care practices should occur at both community and health facility levels as part of a universal coverage strategy.
– Efforts should be made to bridge the “policy-to-practice gap” to ensure that neonatal interventions reach newborns.

Key Role Players:

– Makerere University
– Iganga-Mayuge Demographic Surveillance Site
– Local government health facilities
– Traditional birth attendants
– Field assistants
– DSS staff
– Village-based demographic scouts

Cost Items for Planning Recommendations:

– Training for field assistants
– Supplies for newborn care practices (clean cutting instruments, clean thread, skin-to-skin wraps, etc.)
– Awareness campaigns and education materials
– Monitoring and evaluation activities
– Coordination and management costs

Força da prova

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a population-based survey conducted in eastern Uganda. The study provides information on socioeconomic differences in the use of newborn care practices. The sample size is relatively small (n = 414), which may limit the generalizability of the findings. However, the study used multiple logistic regression analysis to identify determinants of each composite outcome, which strengthens the evidence. To improve the strength of the evidence, future studies could consider increasing the sample size and conducting a longitudinal study to assess the long-term impact of newborn care practices.

Resumo

The study was conducted in the Makerere University-operated Iganga-Mayuge Demographic Surveillance Site (DSS) located in eastern Uganda, about 120 km east of the capital Kampala. The Basoga contribute about 10% of the population of Uganda, but their practices are similar to those of other Bantu ethnic groups who are the majority in Uganda. Eighty percent of the population are peasants and live on less than US$1 a day. An estimated 49% of women and 68% of men are literate (Iganga District Local Government 2008). Traditional birth attendants (TBAs) are significant actors in the provision of antenatal and delivery care in the district. At the time of the study, there were no specific interventions promoted to target the newborn, either at facility or community level. About 30% of the DSS population lives in peri-urban settings with relatively better access to health care compared to their rural counterparts. The DSS has a population of about 67,200 people in 65 villages, 18 parishes and 12,000 households. The household and community structures have been mapped using the Global Positioning System. Over forty locally recruited field assistants whose minimum education is upper secondary school level collect data from each household every fourth month and are supervised by a group of DSS staff from a central office. Village-based demographic scouts notify DSS staff of all deaths and births in the area as they occur on a continuous basis. The DSS area has 13 health facilities of which ten are government facilities including the district hospital, the other three being non-Governmental organisation facilities. The area is also served by over 120 pharmacies and private clinics. The neonatal and post-neonatal mortality rates in the DSS are estimated at 22.3 and 55.2 per 1000 live births, which compares very well with estimates for the entire region as reported in the national demographic health survey (24 and 50 per 1000 live births) [8]. This population-based cross-sectional study represents socio-demographic, SES, and antenatal and newborn care practices among Ugandan women with a baby aged 1-4 months (n = 414). Socio-demographic and household SES information were collected in a separate survey a year earlier. Socio-demographic information, as collected from the DSS, included age, level of education, occupation, religion, tribe, birth order, and sex of the reference child. Household SES is represented by household assets. The DSS field assistants underwent a three day training to use the survey tool which had been translated into Lusoga, the local language in the area. The training included piloting the tool among 25 mothers attending a postnatal clinic at the local hospital. The survey was conducted from March to August 2007. Mothers who had had a stillbirth (data not available) or a neonatal death (64 neonates) were not interviewed for this study. Data collected in this study included information about antenatal care (ANC) practices (attendance, place of attendance, number of visits made, HIV testing, birth preparedness, use of drugs to prevent malaria in pregnancy, and provider of ANC) and delivery (place, time of labour onset and type of attendant at delivery). Women were also asked about their experiences with ENC practices, including type of instrument used to cut the cord, type of material used to tie the cord, when the newborn was first dried and wrapped, length of time before the newborn was bathed the first time, whether any pre-lacteal feeds were given, length of time (hours/days) before breastfeeding was first initiated, and whether the baby was exclusively breastfed during the first month of life. The quality assurance of data was through daily assessment via questionnaires filled-in by a supervisor; in cases of error or incompleteness of data, corrective measures were implemented immediately. Data were entered using FoxPro and cleaned, linked with the DSS database, and then transferred to STATA, version 10, for analysis. For SES, we used the same group of context-specific assets used by the Uganda Bureau of Statistics. These items were screened for relevance, and reliability testing was done using Cronbach’s alpha [12]. The final list included the number of sleeping rooms, type of floor material, type of roof material, wall material, fuel used for cooking and source of light. Other variables were households having or not having the following items: a radio, a sewing machine, an electric flat iron, type of bed, charcoal flat iron, a bed net, kerosene lamp, kerosene stove, car, tea table, refrigerator, television set, sound stereo, telephone, mattress, wheel barrow, cell phone and camera. These gave a Cronbach’s alpha of 0.848. Principal component analysis (PCA) was performed and the first principal component was scored to create an asset index that was used to group all households in the DSS into wealth quintiles [13]. Using the following twelve ANC/ENC practices, we calculated the mean and median number of practices accessed by the mother/newborn: ANC, tetanus toxoid, antimalarial use during pregnancy, HIV test, and insecticide treated net (ITN) use, anemia drugs, clean birth, facility delivery, safe cord care, optimal thermal care, good breastfeeding, and ITN after birth. The following composite outcome variables were then created: (i) Good cord care (defined as use of a clean cutting instrument to cut the umbilical cord plus clean thread to tie the cord plus no substance applied to the cord); (ii) Optimal thermal care (defined as baby put skin-to-skin at birth or wrapped at birth plus first bath after 6 or more hours); and (iii) Good neonatal breastfeeding (defined as initiating breastfeeding within the first one hour after birth plus baby given no supplements at all in the first month of life). These composite variables were then dichotomised to Yes (all practices present) or No (one or more practices missing). The data were then subjected to standard descriptive analysis. Chi-square statistics were performed to compare the levels of each of the dependent variables with the explanatory variables. A multiple logistic regression model was constructed for each dichotomised outcome variable using all of the explanatory variables which were significant at bivariate analysis at a p-value of 0.05 or less after confirming absence of multi-colleneraity between the independent variables. The study was approved following ethical review by the Makerere University School of Public Health Institutional Review Board. As per the DSS routines for non-intrusive research verbal consent was sought from each mother after reading to her about and adequately explaining the purpose of the study. Participants were told that they were free not to participate or to withdraw during any stage of the interview. In addition, field assistants were trained to refer sick mothers/newborn babies with problems to the nearby government health facilities where treatment is provided free of charge.

Materiais

N/A

Inovações

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile health clinics: Implementing mobile health clinics that travel to rural areas, where access to healthcare facilities is limited, can provide essential maternal health services to pregnant women and new mothers.

2. Community health workers: Training and deploying community health workers who can provide education, support, and basic healthcare services to pregnant women and new mothers in their own communities.

3. Telemedicine: Using telecommunication technology to connect pregnant women and new mothers with healthcare professionals, allowing them to receive medical advice and support remotely.

4. Maternal health vouchers: Introducing a voucher system that provides pregnant women with access to essential maternal health services, such as antenatal care, skilled birth attendance, and postnatal care.

5. Public-private partnerships: Collaborating with private healthcare providers to improve access to maternal health services, particularly in underserved areas.

6. Health education programs: Implementing comprehensive health education programs that focus on maternal health, including topics such as prenatal care, nutrition, breastfeeding, and newborn care.

7. Maternal waiting homes: Establishing maternal waiting homes near healthcare facilities, where pregnant women can stay closer to the facility as they approach their due date, ensuring timely access to skilled birth attendance.

8. Transportation support: Providing transportation support, such as ambulances or transportation vouchers, to pregnant women in remote areas to ensure they can reach healthcare facilities in a timely manner.

9. Strengthening referral systems: Improving the coordination and effectiveness of referral systems between community health centers, primary healthcare facilities, and higher-level hospitals to ensure seamless access to appropriate maternal health services.

10. Financial incentives: Introducing financial incentives, such as cash transfers or conditional cash transfers, to encourage pregnant women to seek and utilize maternal health services.

These innovations aim to address the challenges identified in the study and improve access to maternal health services, ultimately reducing maternal and neonatal mortality rates.

AI Innovations Description

Based on the information provided, the recommendation to improve access to maternal health and address the poor newborn care practices in eastern Uganda is to implement a comprehensive intervention strategy that integrates newborn care into existing maternal and child health interventions. This strategy should be implemented at both the community and health facility levels as part of a universal coverage approach.

Specific recommendations include:

1. Strengthening antenatal care (ANC) practices: Ensure that all pregnant women have access to quality ANC services, including regular check-ups, HIV testing, and counseling on newborn care practices. Emphasize the importance of good cord care, optimal thermal care, and adequate neonatal feeding during ANC visits.

2. Promoting facility-based deliveries: Encourage pregnant women to deliver their babies in health facilities where skilled birth attendants can provide proper newborn care. This can be achieved through community sensitization campaigns, providing transportation support, and improving the quality of care in health facilities.

3. Training and capacity building: Provide training and capacity building for healthcare providers, including traditional birth attendants (TBAs), on evidence-based newborn care practices. This should include proper cord care, thermal care, and breastfeeding support.

4. Community engagement and awareness: Conduct community awareness campaigns to educate mothers, families, and community members about the importance of newborn care practices. This can be done through community meetings, radio programs, and the use of local influencers and leaders.

5. Monitoring and evaluation: Establish a robust monitoring and evaluation system to track the implementation and impact of the intervention. Regular assessments should be conducted to measure the coverage and quality of newborn care practices, identify gaps, and inform programmatic adjustments.

6. Collaboration and coordination: Foster collaboration and coordination among key stakeholders, including government agencies, non-governmental organizations, and community-based organizations, to ensure a comprehensive and integrated approach to improving access to maternal health.

By implementing these recommendations, it is expected that access to maternal health services will be improved, leading to better newborn care practices and ultimately reducing neonatal mortality rates in eastern Uganda.

AI Innovations Methodology

Based on the information provided, here are some potential recommendations to improve access to maternal health:

1. Strengthening antenatal care (ANC) services: Implementing interventions to increase ANC attendance, improve the quality of care provided during ANC visits, and ensure that essential services such as HIV testing, tetanus toxoid vaccination, and malaria prevention are consistently offered.

2. Promoting facility-based deliveries: Encouraging pregnant women to deliver in health facilities by addressing barriers such as distance, cost, and cultural preferences for home births. This can be done through community education, providing transportation support, and improving the availability and quality of maternity services in health facilities.

3. Enhancing newborn care practices: Implementing interventions to improve newborn care practices, including proper cord care, optimal thermal care, and exclusive breastfeeding. This can be achieved through community-based education programs, training of healthcare providers, and ensuring the availability of necessary supplies and equipment.

4. Strengthening the role of traditional birth attendants (TBAs): Collaborating with TBAs to improve their knowledge and skills in providing safe and effective maternal and newborn care. This can be done through training programs, supportive supervision, and integration of TBAs into the formal healthcare system.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Baseline data collection: Gather information on the current status of maternal health access, including indicators such as ANC attendance, facility-based deliveries, and newborn care practices. This can be done through surveys, interviews, and analysis of existing data sources.

2. Define the target population: Identify the specific population or geographic area that will be the focus of the simulation. This could be a specific region, district, or community.

3. Develop a simulation model: Create a mathematical or statistical model that represents the relationships between the recommended interventions and the desired outcomes. This model should consider factors such as population size, demographics, healthcare infrastructure, and socio-cultural context.

4. Input data and parameters: Input the baseline data collected in step 1 into the simulation model. Define the parameters and assumptions related to the recommended interventions, such as the coverage and effectiveness of ANC services, facility-based deliveries, and newborn care practices.

5. Run the simulation: Use the simulation model to project the potential impact of the recommended interventions on improving access to maternal health. This could include estimating changes in ANC attendance rates, facility-based delivery rates, and newborn care practices.

6. Analyze the results: Evaluate the simulation results to assess the potential impact of the recommended interventions. This could involve comparing the projected outcomes with the baseline data and identifying any significant improvements or disparities.

7. Refine and iterate: Based on the analysis of the simulation results, refine the model and assumptions as needed. Repeat the simulation process to further explore different scenarios and potential strategies for improving access to maternal health.

It is important to note that simulation models are simplifications of complex real-world systems and may have limitations. Therefore, the results should be interpreted with caution and considered alongside other evidence and contextual factors when making decisions and implementing interventions to improve access to maternal health.

Autores & Coautores

Statistics:

Citations: 85

Authors: 4

Identifiers:

DOI: 10.1186/1471-2393-10-9

Research Areas:

Community Interventions, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Uganda

Study Design:

Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Male & Female

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