Association of antenatal care and place of delivery with newborn care practices: evidence from a cross-sectional survey in rural Uttar Pradesh, India

First 72-hours after birth: Newborn feeding practices and neonatal mortality in India

BACKGROUND

The reductions in mortality levels among children under five years are observed in most populations, including populations that were lagging the progress in the past. However, the reduction is not uniform across ages during childhood. The mortality declines within the first month have shown relatively slow progress. Early initiation of breastfeeding and discarding pre-lacteal feed protects the newborn from acquiring infection and, thereby, reduces mortality. This paper assesses the change in the prevalence of early initiation of breastfeeding and pre-lacteal feed along with their associated factors, and their association with neonatal mortality in India.

METHODS

We used data from the three rounds of National Family Health Surveys conducted during 2005-06, 2015-16 and 2019-21 in India. We used bivariate and multivariate analyses to examine prevalence rates, risk factors, and relationships between breastfeeding practices, including early initiation of breastfeeding and pre-lacteal feed, and neonatal mortality.

RESULTS

Early initiation of breastfeeding within one hour after birth increased rapidly from 25% in 2005-06 to 42% in 2019-21, and the pre-lacteal feeding practice declined from 57% in 2005-06 to 15% in 2019-21. Pre-lacteal feed is lower in states/districts where early breastfeeding initiation is predominant and vice versa. The role of health professionals during pregnancy and the first two days after delivery significantly improved breastfeeding practice. Further, the findings suggest that an early breastfeeding initiation is associated with lower neonatal mortality, whereas pre-lacteal feed is not harmful compared to late breastfeeding initiation.

CONCLUSION

Prevalence of pre-lacteal feed reduced, and initiation of early breastfeeding increased considerably after the launch of the National Rural Health Mission in India. However, after 2015-16, early breastfeeding initiation has stagnated, and the decline in pre-lacteal feed has slowed down. The future program needs special attention to emphasize the availability and accessibility of breastfeeding advisers and observers in health facilities to help mitigate adverse neonatal outcomes.

A multilevel analysis to determine the factors affecting WHO recommended quantity antenatal care utilizations of pregnant women in Bangladesh

Antenatal Care utilizations have become an essential phenomenon to all pregnant women as a means of disease preclusion during pregnancy and safe live birth. To lessen maternal death and disease, proper (minimum eight) antenatal care (ANC) contacts are necessary according to World Health Organization (WHO) new guideline. The aim of this study is to assess the factors affecting proper antenatal care utilization of pregnant Bangladeshi women. The study used data from the most recent Bangladesh Demographic and Health Survey 2017-18 for conducting a two-level binary logistic regression model. A weighted sample of 4866 women and 675 clusters were considered as individual and community level respectively. The results exhibited only 11.6% women took proper antenatal care during pregnancy. The study found 23.9% variability in utilizations of Antenatal care belongs to community-level factors. At individual-level, mother's occupation, body mass index, birth-order, pregnancy intention, education, delivery place, and media access and at community-level, rural communities (AOR = 0.70, 95% C.I = 0.542-0.920), and communities having media access (AOR = 1.38, 95% C.I = 0.979-1.96) had significant relationship with proper antenatal care utilizations of pregnant women. After testing random slopes of individual-level variables, only education of women covariate was found to be varied from community to community. This study suggests that uptake of proper antenatal care depend on both individual and community level covariates and there lies extensive variation among them. Future studies on wider aspect are therefore suggested to determine obstacles in making proper Antenatal care utilizations.

Home delivery among pregnant women with ANC follow-up in Ethiopia; Evidence from the 2019 Ethiopia mini demographic and health survey

Background

Maternal mortality has remained an international public health problem although it is decreasing in recent years. Developing countries particularly Sub-Saharan African countries bears the high burden of maternal deaths. There was no study conducted to assess prevalence and associated factors of home delivery among women in Ethiopia on antenatal care (ANC) follow up nationally. Therefore, this study was conducted to assess the magnitude and associated factors of home delivery in Ethiopia.

Objectives

To assess the magnitude of home delivery and associated factors among women who had ANC follow up in Ethiopia.

Methods

Secondary data analysis was carried out using Ethiopian Mini Demography and Health Survey (EMDHS 2019). A total weighted sample of 2,143 women who had ANC follow up during pregnancy was incorporated in the study. In a generalized linear mixed model (GLMM), Adjusted Odds Ratio (AOR) with a 95% Confidence Interval (CI) and p < 0.05 were declared as associated factors of home delivery.

Results

The prevalence of home delivery was 31.27% [95% CI: 29.34%, 33.27%] among women who had ANC follow up in Ethiopia. Attended higher education [AOR = 0.27; 95% CI: (0.13, 0.54)], rural resident [AOR = 2.15; 95% CI: (1.19, 3.90)], richest in the wealth index [AOR = 0.18; 95% CI: (0.10, 0.32)], had adequate ANC follow up [AOR = 0.25; 95% CI: (0.13, 0.51)] and being in third trimesters [AOR = 0.64; 95% CI: (0.49, 0.83)] during first ANC visit were significantly associated factors of home delivery.

Conclusion

Near to one-third of women in Ethiopia have delivered their babies at home even if they had an ANC follow up. Educational status, place of residence, wealth index, timing of first antenatal check and adequate ANC visit has shown significant association with home delivery. Therefore, focused intervention packages need to be implemented at all levels of the health care system in Ethiopia to improve health seeking behaviors of women who have ANC follow up to have delivery in health care institutions. While doing so, special attention should be given for poor, uneducated and rural dweller women.

Improving birth preparedness and complication readiness in rural India through an integrated microfinance and health literacy programme: evidence from a quasi-experimental study

OBJECTIVE

Recently, a novel community health programme-the integrated microfinance and health literacy (IMFHL) programme was implemented through microfinance-based women's only self-help groups (SHGs) in India to promote birth preparedness and complication readiness (BPCR) to improve maternal health. The study evaluated the impact of the IMFHL programme on BPCR practice by women in one of India's poorest states-Uttar Pradesh-adjusting for the community, household and individual variables. The paper also examined for any diffusion of knowledge of BPCR from SHG members receiving the health literacy intervention to non-members in programme villages.

DESIGN

Quasi-experimental study using cross-sectional survey data.

SETTINGS

Secondary survey data from the IMFHL programme were used.

PARTICIPANTS

Survey data were collected from 17 244 women in households with SHG member and non-member households in rural India.

PRIMARY OUTCOMES

Multivariable logistic regression was used to estimate main and adjusted IMFHL programme effects on maternal BPCR practice in their last pregnancy.

RESULTS

Membership in SHGs alone is positively associated with BPCR practice, with 17% higher odds (OR=1.17, 95% CI 1.07 to 1.29, p<0.01) of these women practising BPCR compared with women in villages without the programmes. Furthermore, the odds of practising complete BPCR increase to almost 50% (OR=1.48, 95% CI 1.35 to 1.63, p<0.01) when a maternal health literacy component is added to the SHGs. A diffusion effect was found for BPCR practice from SHG members to non-members when the health literacy component was integrated into the SHG model.

CONCLUSIONS

The results suggest that SHG membership exerts a positive impact on planned health behaviour and a diffusion effect of BPCR practice from members to non-members when SHGs are enriched with a health literacy component. The study provides evidence to guide the implementation of community health programmes seeking to promote BPCR practise in low resource settings.

Intersectional (in) equities in contact coverage of maternal and newborn health services in Nepal: insights from a nationwide cross-sectional household survey

Background

Persistent inequities in coverage of maternal and newborn health (MNH) services continue to pose a major challenge to the health-care system in Nepal. This paper uses a novel composite indicator of intersectional (dis) advantages to examine how different (in) equity markers intersect to create (in) equities in contact coverage of MNH services across the continuum of care (CoC) in Nepal.

Methods

A secondary analysis was conducted among 1978 women aged 15–49 years who had a live birth in the two years preceding the survey. Data were derived from the Nepal Demographic and Health Survey (NDHS) 2016. The three outcome variables included were 1) at least four antenatal care (4ANC) visits, 2) institutional delivery, and 3) postnatal care (PNC) consult for newborns and mothers within 48 h of childbirth. Independent variables were wealth status, education, ethnicity, languages, residence, and marginalisation status. Intersectional (dis) advantages were created using three socioeconomic variables (wealth status, level of education and ethnicity of women). Binomial logistic regression analysis was employed to identify the patterns of (in) equities in contact coverage of MNH services across the CoC.

Results

The contact coverage of 4ANC visits, institutional delivery, and PNC visit was 72, 64, and 51% respectively. Relative to women with triple disadvantage, the odds of contact coverage of 4ANC visits was more than five-fold higher (Adjusted Odds Ratio (aOR) = 5.51; 95% CI: 2.85, 10.64) among women with triple forms of advantages (literate and advantaged ethnicity and higher wealth status). Women with triple advantages were seven-fold more likely to give birth in a health institution (aOR = 7.32; 95% CI: 3.66, 14.63). They were also four times more likely (aOR = 4.18; 95% CI: 2.40, 7.28) to receive PNC visit compared to their triple disadvantaged counterparts.

Conclusions

The contact coverage of routine MNH visits was low among women with social disadvantages and lowest among women with multiple forms of socioeconomic disadvantages. Tracking health service coverage among women with multiple forms of (dis) advantage can provide crucial information for designing contextual and targeted approaches to actions towards universal coverage of MNH services and improving health equity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11142-8.

Association of prenatal counselling and immediate postnatal support with early initiation of breastfeeding in Uttar Pradesh, India

BACKGROUND

Timely initiation of breastfeeding, also known as early initiation of breastfeeding, is a well-recognized life-saving intervention to reduce neonatal mortality. However, only one quarter of newborns in Uttar Pradesh, India were breastfed in the first hour of life. This paper aims to understand the association of community-based prenatal counselling and postnatal support at place of delivery with early initiation of breastfeeding in Uttar Pradesh, India.

METHODS

Data from a cross-sectional survey of 9124 eligible women (who had a live birth in 59 days preceding the survey) conducted in 25 districts of Uttar Pradesh, India, in 2018, were used. Simple random sampling was used to randomly select 40 Community Development Blocks (sub district administrative units) in 25 districts. The Primary Sampling Units (PSUs), health service delivery unit for frontline workers, were selected randomly from a linelisting of PSUs in each selected Community Development Block. Bivariate and multivariate logistic regression analyses were performed to assess the association of prenatal counselling and postnatal support on early initiation of breastfeeding in public, private and home deliveries.

RESULTS

Overall 48.1% of mothers initiated breastfeeding within an hour, with major variation by place of delivery (61.2% public, 23.6% private and 32.6% home). The adjusted odds ratio (aOR) of early initiation of breastfeeding was highest among mothers who received both counselling and support (aOR 2.67; 95% CI 2.30, 3.11), followed by those who received only support (aOR 1.99; 95% CI 1.73, 2.28), and only counselling (aOR 1.40; 95% CI 1.18, 1.67) compared to mothers who received none. The odds of early initiation of breastfeeding was highest among mothers who received both prenatal counselling and postnatal support irrespective of delivery at public health facilities (aOR 2.49; 95% CI 2.07, 3.01), private health facilities (aOR 3.50; 95% CI 2.25, 5.44), or home (aOR 2.84; 95% CI 2.02, 3.98).

CONCLUSIONS

A significant association of prenatal counselling and postnatal support immediately after birth on improving early initiation of breastfeeding, irrespective of place of delivery, indicates the importance of enhancing coverage of both the interventions through community and facility-based programs in Uttar Pradesh.

The knowledge of danger signs of obstetric complications among women in rural India: evaluating an integrated microfinance and health literacy program

BACKGROUND

Maternal mortality can be prevented in low-income settings through early health care seeking during maternity complications. While health system reforms in India prioritised institutional deliveries, inadequate antenatal and postnatal services limit the knowledge of danger signs of obstetric complications to women, which delays the recognition of complications and seeking appropriate health care. Recently, a novel rapidly scalable community-based program combining maternal health literacy delivery through microfinance-based women-only self-help groups (SHG) was implemented in rural India. This study evaluates the impact of the integrated microfinance and health literacy (IMFHL) program on the knowledge of maternal danger signs in marginalised women from one of India's most populated and poorer states - Uttar Pradesh. Additionally, the study evaluates the presence of a diffusion effect of the knowledge of maternal danger signs from SHG members receiving health literacy to non-members in program villages.

METHODS

Secondary data from the IMFHL program comprising 17,232 women from SHG and non-member households in rural Uttar Pradesh was included. Multivariate logistic regression models were used to identify the program's effects on the knowledge of maternal danger signs adjusting for a comprehensive range of confounders at the individual, household, and community level.

RESULTS

SHG member women receiving health literacy were 27% more likely to know all danger signs as compared with SHG members only. Moreover, the results showed that the SHG network facilitates diffusion of knowledge of maternal danger signs from SHG members receiving health literacy to non-members in program villages. The study found that the magnitude of the program impact on outcome remained stable even after controlling for other confounding effects suggesting that the health message delivered through the program reaches all women uniformly irrespective of their socioeconomic and health system characteristics.

CONCLUSIONS

The findings can guide community health programs and policy that seek to impact maternal health outcomes in low resource settings by demonstrating the differential impact of SHG alone and SHG plus health literacy on maternal danger sign knowledge.

Bringing Greater Precision to Interactions Between Community Health Workers and Households to Improve Maternal and Newborn Health Outcomes in India

INTRODUCTION

Community health workers (CHWs) play a key role in the health of mothers and newborns in low- and middle-income countries. However, it remains unclear by what actions and messages CHWs enable good outcomes and respectful care.

METHODS

We collected a uniquely linked set of questions on behaviors, beliefs, and care pathways from recently delivered women (n=5,469), their husbands (n=3,064), mothers-in-law (n=3,626), and CHWs (accredited social health activists; n=1,052) in Uttar Pradesh, India. We used logistic regression to study associations between CHW actions and household behaviors during antenatal, delivery, and postnatal periods.

RESULTS

Pregnant women who were visited earlier in pregnancy and who received multiple visits were more likely to perform recommended health behaviors including attending multiple checkups, consuming iron and folic acid tablets, and delivering in a health facility (ID), compared to women visited later or receiving fewer visits, respectively. Counseling the woman was associated with higher likelihood of attending 3+ checkups and consuming 100+ iron and folic acid tablets, whereas counseling the husband and mother-in-law was associated with higher rates of ID. Certain behavior change messages, such as the danger of complications, were associated with more checkups and ID, but were only used by 50%-80% of CHWs. During delivery, 57% of women had the CHW present, and their presence was associated with respectful care, early initiation of breastfeeding, and exclusive breastfeeding, but not with delayed bathing or clean cord care. The newborn was less likely to receive delayed bathing if the CHW incorrectly believed that newborns could be bathed soon after birth (which is believed by 30% of CHWs). CHW presence was associated with health behaviors more strongly for home than facility deliveries. Home visits after delivery were associated with higher rates of clean cord care and exclusive breastfeeding. Counseling the mother-in-law (but not the husband or woman) was associated with exclusive breastfeeding.

CONCLUSION

We identified potential ways in which CHW impact could be improved, specifically by emphasizing the importance of home visits, which household members are targeted during these visits, and what messages are shared. Achieving this change will require training CHWs in counseling and behavior change and providing supervision and modern tools such as apps that can help the CHW keep track of her beneficiaries, suggest behavior change strategies, and direct attention to households that stand to gain the most from support.

Reaching health facilities in situations of emergency: qualitative study capturing experiences of pregnant women in Africa's largest megacity

Background

The consequences of delays in travel of pregnant women to reach facilities in emergency situations are well documented in literature. However, their decision-making and actual experiences of travel to health facilities when requiring emergency obstetric care (EmOC) remains a ‘black box’ of many unknowns to the health system, more so in megacities of low- and middle-income countries which are fraught with wide inequalities.

Methods

This in-depth study on travel of pregnant women in Africa’s largest megacity, Lagos, is based on interviews conducted between September 2019 and January 2020 with 47 women and 11 of their relatives who presented at comprehensive EmOC facilities in situations of emergency, requiring some EmOC services. Following familiarisation, coding, and searching for patterns, the data was analysed for emerging themes.

Results

Despite recognising danger signs, pregnant women are often faced with conundrums on “when”, “where” and “how” to reach EmOC facilities. While the decision-making process is a shared activity amongst all women, the available choices vary depending on socio-economic status. Women preferred to travel to facilities deemed to have “nicer” health workers, even if these were farther from home. Reported travel time was between 5 and 240 min in daytime and 5–40 min at night. Many women reported facing remarkably similar travel experiences, with varied challenges faced in the daytime (traffic congestion) compared to night-time (security concerns and scarcity of public transportation). This was irrespective of their age, socio-economic background, or obstetric history. However, the extent to which this experience impacted on their ability to reach facilities depended on their agency and support systems. Travel experience was better if they had a personal vehicle for travel at night, support of relatives or direct/indirect connections with senior health workers at comprehensive EmOC facilities. Referral barriers between facilities further prolonged delays and increased cost of travel for many women.

Conclusion

If the goal, to leave no one behind, remains a priority, in addition to other health systems strengthening interventions, referral systems need to be improved. Advocacy on policies to encourage women to utilise nearby functional facilities when in situations of emergency and private sector partnerships should be explored.

Essential newborn care utilization and associated factors in Ethiopia: a systematic review and meta-analysis

Background

Globally, newborn death accounted for 46% of under-five deaths and more than 80% of newborn deaths are the result of preventable and treatable conditions. Findings on the prevalence and associated factors of essential newborn care utilization are highly variable and inconsistent across Ethiopia. Therefore, this systematic review and meta-analysis aimed to estimate the pooled prevalence of essential newborn care utilization and associated factors in Ethiopia.

Methods

The international databases accessed included MEDLINE/PubMed, EMBASE, Web of Sciences, Scopus, and Grey literature databases, Google Scholar, Science Direct and Cochrane library were scientifically explored. We considered all primary studies reporting the prevalence of essential newborn care utilization and associated factors in Ethiopia. We retrieved all necessary data by using a standardized data extraction format spreadsheet. STATA 14 statistical software was used to analyze the data and Cochrane Q test statistics and I² test was used to assess the heterogeneity between the studies. There significant heterogeneity between the studies so a random effect model was employed.

Results

The pooled estimate of essential newborn care utilization from 11 studies in Ethiopia was 48.77% (95% CI: 27.89, 69.65). Residence [OR = 2.50 (95% CI: 1.64, 3.88)], Postnatal care [OR = 5.53, 95% CI = (3.02, 10.13], counseling during pregnancy and delivery [OR = 4.39, 95% CI = (2.99, 6.45], antenatal care follows up (OR = 6.84; 95% CI: 1.15, 4.70) and maternal educational status [OR = 1.63 (95% CI: 1.12, 2.37)] were identified as associated factors of essential newborn care utilization.

Conclusion

Based on the current study essential newborn care utilization in Ethiopia was significantly low in comparison with the current global recommendation on essential newborn care utilization. Place of residence, Postnatal care, counseling during pregnancy and delivery, antenatal care follow up, and maternal educational status were associated risk factors. Therefore, on the basis of the results, it is suggested that special attention should be given to attempts to ensure that education should focus on women during ante and postnatal follow-up, counseling during pregnancy and delivery, as well as rural and illiterate mothers. Finally, appropriate newborn services at health facilities and raising mother’s level of awareness about newborn care practices are imperative in addressing the gaps in essential newborn care utilization in Ethiopia.

Does antenatal care service quality influence essential newborn care (ENC) practices? In Bahir Dar City Administration, North West Ethiopia: a prospective follow up study

Background

The neonatal period is only 1/60th of the first 5 years of life but it accounts for 63% of all infant deaths and 44% of all under-five deaths in Ethiopia. Most causes of neonatal death are preventable with clean cord care, temperature control by delaying first bath and initiation of early breastfeeding which has additional benefit of controlling hypothermia. Poor positive pressure ventilation (PPV) with ambubag is also another essential neborn care practice to reduce neonatal death even though it was not the focus of this study with the assumption that it cannot be measured only by exit interview (needs direct observation about the procedure).

This study was aimed to assess the link between quality of ANC service and implementation of essential newborn care practices among pregnant women attending ANC at public health facilities of BDR City Administration.

Methods

A facility based prospective follow up study was conducted and 970 pregnant women with gestational age ≤ 16 weeks who came for their first ANC visit were enrolled. Women were followed from their first ANC visit until 6 weeks after delivery. Longitudinal data was collected during consultation with ANC providers using structured observation checklist and exit interview was also carried out at 6 weeks after birth when they came to immunize their child to assess the essential newborn care practices that their babies received. ANC service was considered as acceptable quality if women received ≥75th percentile of the essential ANC services. Generalized Estimating Equation (GEE) was carried out to control cluster effect among women who received ANC in the same facility.

Results

The composite essential newborn care practice indices were 13.7%, with 95% CI (11.3%, 16.2%) and 86.3%, with 95% CI (83.8%, 88.7%) for good and poor essential new born care practices respectively. Of those who received acceptable ANC quality and un acceptable ANC quality 24.7% and 9.6% had good essential newborn care practice respectively (X² = 31.668, p < 0.000).

Conclusions

Most neonatal interventions are not reaching newborns, indicating a “policy-to practice gap”. It is crucial that maternal knowledge about essential newborn care need to start before the baby’s birth with an effective educational plan.

Quality ANC service is a facilitator for essential newborn care practice. To improve newborn survival, newborn care should be integrated into the current maternal and child health interventions, and should be promoted both at community and health facility level as part of a universal coverage strategy.

Electronic supplementary material

The online version of this article (10.1186/s13052-018-0544-3) contains supplementary material, which is available to authorized users.