Qualitative Research to Improve Newborn Care Practices

8/8/2019 Qualitative Research to Improve Newborn Care Practices

1/52

Saving Newborn Lives Initiative

SAVING NEWBORN LIVESTOOLS FOR NEWBORN HEALTH

QUALITATIVE RESEARCH

TO IMPROVE NEWBORN

CARE PRACTICESRonald P. Parlato, Gary L. Darmstadt,

and Anne Tinker


2/52

All rights reserved. Publications of Saving Newborn Lives initiative

of Save the Children can be obtained from Saving Newborn Lives,

Save the Children US, 2000 M Street NW, Suite 500,Washington,

DC 20036 (tel: 202-293-4170; fax: 202-637-9362). Requests for

permission to reproduce or translate SNL publications for non-

commercial distribution should be addressed to SNL Public

Affairs Department at the above address.

Save the Children does not warrant that the information con-

tained in this publication is complete and correct and shall not be

liable for any damages incurred as a result of its use.

Printed in the United States of America.

Editor: Robin Bell

Editorial and design assistance: Julia Ruben

Cover design:Kinetik Communications

Front cover photo: Brian Moody

Back cover photo:Thomas Kelly

SAVING NEWBORN LIVES INITIATIVE, supported by the

Bill & Melinda Gates Foundation, is a global initiative to improve

the health and survival of newborns in the developing world. Sav-

ing Newborn Lives works with governments, local communities

and partner agencies in developing countries to make progress

toward real and lasting change in newborn health.

SAVE THE CHILDREN is a leading international nonprofit

child-assistance organization working in over 40 countries world-wide, including the United States. Our mission is to make lasting

positive change in the lives of children in need. Save the Children

is a member of the international Save the Children Alliance, a

worldwide network of 30 independent Save the Children organi-

zations working in more than 100 countries to ensure the well-

being and protect the rights of children everywhere.

Save the Children 2004


3/52

SAVING NEWBORN LIVES

TOOLS FOR NEWBORN HEALTH

Saving Newborn Lives Initiative

Washington, DC

QUALITATIVE RESEARCHTO IMPROVE NEWBORN

CARE PRACTICES

Ronald P. Parlato, Gary L. Darmstadt,

and Anne Tinker


4/52

B


5/52

ii

Many people put their thoughts, time, and effort into the shape and content of this publication. Theauthors wish to thank Nancy Nachbar and Annette Bongiovanni of the Academy for EducationalDevelopment, who made valuable contributions to early drafts of the document. La Rue Seims of

Saving Newborn Lives, Save the Children, prepared parts of Chapter 4. Our thanks also go toClaudia Fishman of CDC, Peter Winch of Johns Hopkins University, Jose Martines of WHO, NitaBhandari of AIIMS, Alessandra Bazzano of the London School of Hygiene, and Steven Wall, DavidMarsh, Frances Ganges, Malia Boggs, and Nabeela Ali of Save the Children, all of whom helped withtheir technical review. The authors are also grateful to David Oot, Director of the Office of Health,Save the Children, for his continued support and advice. Sarah Holland, Julia Ruben, Michael Foley,and Megan Renner deserve acknowledgment for for their assistance in the preparation of the docu-ment. Finally, the authors wish to thank all SNL staff who field-tested this guide and offered timely

and useful comments throughout the development process.

Without the generousity of the Bill & Melinda Gates Foundation, Saving Newborn Lives would notbe able to adapt qualitative research tools to the urgent goal of reducing newborn deaths. Our thanksto the Gates Foundation for its support and guidance.

ACKNOWLEDGMENTS


6/52

blank


7/52

iii

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ii

Table of Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iiiHow to Use this Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Chapter 1: Antenatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Chapter 2: Intrapartum Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Chapter 3: Postnatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Chapter 4: Research Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

Chapter 5: Applying Data Analysis to BCC Planning and Programming . . . . . . . . . . . . . . . . . . . .33

Appendix: Qualitative Research Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

TABLES AND FIGURES

Figure 1. Essential Newborn Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Table 1. All ENC Periods: Constraints and Lines of Inquiry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Table 2. Antenatal Period: Lines of Inquiry about Current Practices . . . . . . . . . . . . . . . . . . . . . . .13

Table 3. Antenatal Period: Constraints and Lines of Inquiry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Table 4. Intrapartum Care: Lines of Inquiry about Current Practices . . . . . . . . . . . . . . . . . . . . . .18

Table 5. Intrapartum Care: Lines of Inquiry about Constraints . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Table 6. Immediate Newborn Care: Lines of Inquiry about Current Practices . . . . . . . . . . . . . . .22

Table 7. Immediate Newborn Care: Lines of Inquiry about Constraints . . . . . . . . . . . . . . . . . . . .24

Table 8. Neonatal Care: Lines of Inquiry about Current Practices . . . . . . . . . . . . . . . . . . . . . . . . .26

Table 9. Neonatal Care: Lines of Inquiry about Constraints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

Table 10. Qualitative Research: Methods and Examples of Newborn Care Applications . . . . . . . .30

Table 11. Analyzing Qualitative Data and Developing a BCC Strategy . . . . . . . . . . . . . . . . . . . . . . .35

CONTENTS


8/52

blank


9/52

How to Use this Guide 1

The purpose of this guide is to provide a readyreference tool for conducting qualitative researchand planning a behavior change communicationsstrategy to improve newborn care practices. Inthis guide, we label this research qualitative, butit is important to note that the term formative

can be used to describe it as well. The guide hasbeen designed with the understanding that thequalitative research and analysis could be carriedout by subcontracted technical agencies or individuals who would supply the information toprogram managers. The program manager will

not design, develop, or execute field studies, butrather will provide terms of reference and

informed technical supervision and manage-ment.

No matter how well-qualified, the researcher maybe new to the subjects of Essential NewbornCare (ENC) and Behavior Change Communication(BCC). In this regard, this guide will help orientthe program manager and the researcher to thesetechnical areas and help to ensure that the

research remains focused to generate informationthat will inform the design of BCC programs.

This guide provides:

Evidence-based practices that have beenshown to have the most significant and directimplications for newborn health, mortality

and morbidity.1These are the target practicesfrom which to choose while designing the

qualitative research. It is strongly recom-mended that only practices from this list beselected to ensure consistency and maintain a

focus on evidence-based practices.

Methods to identify the current practices oflocal communities and lists ofconstraintsinformational, social, cultural, economic, or

supply factors shown in prior qualitativeresearch studies to limit or discourage theadoption of evidence-based ENC practices. This guide also provides sample lines ofinquiry that correspond to each currentpractice and constraint. These lines of

inquiry are designed to suggest where andhow to look for answers; however, they willneed to be adapted for direct use in qualita-tive research questionnaires.

Guidelines for identifyingtarget audiences

and assessing the decision-makingprocesses of their members. This can

include assessing family decision-making. This can also include eliciting informationabout those members of the community,other than the extended family, who areinfluential in ENC decision-makingsuch astraditional practitioners and facility-basedhealth workers. Not only is it important toidentify who is exerting influence overimportant ENC decisions, but it is also

imperative to understand the beliefs of thoseinfluential individuals themselves.

Procedures involved in qualitative researchmethods, such as in-depth interviews andfocus group discussions.

Practical guidance on how to move to the next

steps after qualitative researchthe all-impor-tant phases of data analysis and BCC plan-

ning and programming.

Introduction to Chapter Structure

Each of the ENC chapters (Chapters 1 3) ofthe guide includes matrices (Tables 1-9) present-ing comprehensive lines of inquiry for both cur-

rent practices and constraints.

HOW TO USE THIS GUIDE


10/52

2 Qualitative Research to Improve Newborn Care Practices

Each of these chapters is divided into the follow-ing sections:

1. Presentation of evidence-based ENC practicesand sub-practices and a discussion of their

importance, answering the question: Whatproven, evidence-based interventions lead tolower neonatal mortality and morbidity?

2. Presentation of lines of inquiry to determinecurrent ENC practices, answering the ques-tions: What are the current practices, and to what degree or under what circumstances

might they be changed?

3. Presentation of lines of inquiry to determine

those constraints pertaining to each evidence-based practice, answering the question:What factors inhibit or discourage peoplesability and willingness to practice evidence-based ENC?

These chapters address the three temporal peri-ods of care: antenatal, intrapartum, and postna-tal. Within each period there are major evidence-based practices and sub-practices, and for each ofthese there may be a variety of informational,social, cultural, economic, and supply constraintsthat limit or discourage behavior change.

Nevertheless, it is unlikely that program man-agers will have to deal with all practices or all

questions.

Various factors might allow the researcher tofocus and simplify inquiries:

In some cases, a particular evidence-basedpractice is already common in the country. In

Malawi, for example, antenatal care is alreadyunderstood and practiced. Similarly, in manyareas of Bangladesh, exclusive breastfeedingis the norm rather than the exception. Underthese circumstances there is no need foradditional research, for these practices willprobably not require further attention.

Another consideration is whether otheragencies are already addressing certain ENCpractices. Another international organization,

for example, may be implementing or haverecently implemented a program to promotebetter maternal nutrition, exclusive breast-feeding, or tetanus toxoid immunization,thus obviating the need for additionalresearch or programming.

In other cases, although no current or priorprograms exist, there may be a sufficientbody of existing knowledge on the subject.Others may have done exploratory researchthat is sufficient to form the basis for BCCplanning in particular subject areas. In SNLfocus countries, for instance, the baseline

survey may supply enough relevant informa-tion to reduce the need for further invest-ment in certain qualitative research topics.


11/52

Introduction 3

Newborn mortality is one of the worlds most

neglected health problems. It is estimated thatglobally, four million newborns die before theyreach one month of age and another four mil-lion are stillborn each year. Deaths during theneonatal period (the first 28 days of life) accountfor almost two-thirdsof all deaths in the first yearof life and 40 percent of deaths before the age

of five.

Most of these deaths could be preventedthrough proven, cost-effective interventions,

such as tetanus toxoid immunization or exclusivebreastfeeding. The Saving Newborn Lives (SNL)initiative is designed to reduce neonatal mortalityand morbidity by strengthening and expanding

these and other interventions in Africa, Asia, andLatin America.

Behavior Change Communications (BCC) isa process that provides timely, relevant, anduseful information to local communitiesthat can be used to encourage families to

improve newborn care practices. Successfulbehavior change requires a thorough under-

standing of the target audience. Qualitativeresearch provides essential informationabout what could motivate this audience toimprove its newborn care practices.

This guide is intended to discuss behaviorchange within the context of EssentialNewborn Care (ENC) and to provide guide-

lines on how to plan, manage, and use qual-itative research and design a BCC strategy.

Essential Newborn Care Practices

As represented in Figure 1, the SNL initiativefocuses on the three important periods ofENCantenatal, intrapartum (during labor

and delivery), and postnataland promotes a vari-

ety of interventions that have proven effective.

The success of any program designed to pro-mote and improve ENC practices depends onthree key factors:

1. Increasing the demand for ENC practices

2. Providing relevant, appropriate, and usefulinformation to enable individuals to act onthis demand

3. Assuring the supply of those goods and serv-ices necessary to meet this demand

For example, while clean delivery requires thesupply of a clean blade and tie to cut the umbili-cal cord, it first requires that families desire to usethese products. Thus, they need to appreciate thebenefits of a clean blade and tie and also knowhow to use them.

Adapted from:Marsh DR,Darmstadt GL, Moore J, Daly P, Oot D,Tinker A."Advancing Newborn Health and Survival in Developing Countries:AConceptual Framework." J. Perinatology 22 (2002): 572-576

Figure 1:Essential Newborn Care

INTRODUCTION

ANTENATAL CARE

Routine ANC visits

Birth preparedness

Danger signs/complications

IMMEDIATE NEWBORN CARE

Drying and warming

Ensuring breathing/newborn

resuscitation

Immediate breastfeeding

Clean cord care

INTRAPARTUM CARE

Skilled attendance at delivery

Clean delivery

Danger signs/complications

NEONATAL CARE

Routine postnatal care visits

Exclusive breastfeeding

Maintenance of

warmth/cleanliness

Newborn danger

signs/complications

Antenatal

Care

Intrapartum

Care

Postnatal

Care


12/52


Similarly, while birth preparedness requires iden-tifying available transportation and upgradedreferral facilities, it also requires a demand forthese services as well as the ability to pay forthem. On the informational side, families must

first be able to recognize danger signs and com-plications, be confident that referral care will helpensure the survival of mother and newborn, andbe motivated to act on this knowledge.

Some practices, such as immediate and exclusivebreastfeeding or drying and warming the new-born, require little in the way of supplies or

products, but a great deal in the way of convic-tion. A new mother and her family must under-stand the value of immediate and exclusive

breastfeeding, must value it enough to give upthe traditional feeding habits for newborns andinfants, and must be convinced that regardless ofthe practices of other women and their families,this practice will be beneficial for theirchild.

Promoting evidence-based practices for new-born caregivers and modifying practices that areharmful will improve newborn health and reducemortality and morbidity. However, for numerousreasons, demand for evidence-based newborncare practices is often quite low. First, many fam-ilies do not receive the information required tounderstand the relationship between improved

practices and better health outcomes. Second,the presentation of this information may nottake into account existing social, cultural, andeconomic constraints to behavior change. Third, well-established and traditional newborn carepractices may be strongly reinforced by familyand community structures that tend to favor

them over innovation.

Economic constraints are perhaps the most sig-nificant of these barriers to demand for healthservices. Costwhether a simple lack of fundsor opportunity costis a formidable deterrent

to behavior change.2

Social, cultural, and economic constraints are notinsurmountable barriers to change. Under-standing them can assist communications plan-ners to customize the crafting of messages andmedia. In reality, improvements in newborn care

practices have been seen throughout the world.Immediate and exclusive breastfeeding rates haveincreased dramatically in many countries due tosuccessful BCC programs. Social mobilizationcampaigns have increased demand for tetanustoxoid coverage and thus reduced the incidenceof death from a disease for which prevention isabsolutely paramount. BCC initiatives have been

equally successful in increasing rates of antenatalcare and skilled care at birth.

Qualitative Research

Qualitative research offers specialized techniquesfor obtaining and understanding in-depth infor-mation about what people know, think, and do.Qualitative research analyzes social patterns and

traditions that influence decision-making. It con-siders cultural beliefs and convictions that give areligious and philosophical significance to new-born care. It looks at economic constraints thatlimit the ability of families and communities topractice positive behaviors even when they mayhave the knowledge and conviction to do so.

Qualitative research, however, is not merelydescriptive; it is practical, useful, and dynamic. Itinvestigates not only why people do what theydo, but more importantly, what can help them tochange. It provides the BCC planner with ade-quate information to identify the most effectiveentry point for behavior change negotiation, and

the most acceptable and feasible degree ofchange within existing constraints.

An example of how qualitative research data canbe used to design appropriate and persuasivemessages comes from the Hausa population inrural Nigeria. Qualitative research showed thatimmediately after birth, families commonly give


13/52

Introduction 5

newborns water that has been poured over paperon which verses from the Koran have beeninscribeda practice rooted in a centuries-oldtradition. According to Hausa beliefs, this prac-tice provides the vulnerable newborn the protec-

tion of Allah. At the same time, the Hausabelieve that breast milk is good for the newbornand that through drinking breast milk, the new-born eats and drinks what the mother does. ABCC campaign promoting exclusive breastfeed-ing among the Hausa combined these two beliefsinto a communication strategy. If the motherdrinks Koranic verses, it was argued, the benefits

would pass on to the newborn through her breastmilk. Respecting both medical judgment (avoid-ing giving water to the newborn) andthe local tra-

ditions and beliefs of the Hausa population, thecampaign was a success.

In this case and many others, qualitative researchhas provided BCC planners with the client-baseddata on which to ground the development of

communication strategiessuggesting creativeapproaches to balancing demands of a tradition-al society with the value of modern health con-cepts. In short, qualitative research leads to anunderstanding of what people are currentlydoing, why they are doing it, what changes mightbe feasible within the context of existing con-straints, and how communicators might effec-

tively address these changes.

At the same time, qualitative research can helpthe BCC planner rule out those ENC practicesthat might not be the most practical or viable pri-orities. Changing certain practices may simplyrepresent too great a social, cultural, or econom-

ic risk to justify an investment of limited BCCresources. The practice of ritualprelacteal feeds, for

example, is common in many parts of theworldoften tied to long-standing cultural tradi-

tion, social practice, or religious belief.3Althoughthe Hausa were generally open to modifying theirpractice in favor of exclusive breastfeeding, other

communities might consider discontinuing their

practice as a major breach in tradition. Prelactealfeeds often fulfill important sociocultural func-tionsuniting families, reaffirming family roles,sanctifying the life of the newborn, and demon-strating religious respect and homage. It may

only be possible to modify the practice gradually,over the longer term. In general, the potentialhealth impact of a behavior change should beassessed in relation to its feasibility and socialacceptabilitya judgment best made with theparticipation of the target community.

Qualitative research, then, can provide answers

to the following questions:

Which practices are likely to remain unchanged

despite even the best BCC programs?

Which practices have the fewest social, eco-nomic, or cultural constraints and thus aremost amenable to change and most likely tolead to improved health outcomes?

Which practices are amenable to change, butmay not significantly impact health status andthus may not be valuable, cost-effective tar-gets for BCC programs?

For practices that appear amenable to changeand are known to have a significant impact

on health, what might convince families toimprove them?

Constraints4

A constraint is defined as any factor that limitsbehavior change. Several types of constraints are

detailed below:

Informational constraints refer to theclients lack of information regarding cur-rent or recommended ENC practices andtheir health outcomes. That is, aside fromsocial, cultural, and economic constraints, a

major reason for not adopting a new prac-


14/52


tice can simply be lack of knowledge and asound understanding of its availability, use,or benefits.

Social constraints refer to social patterns in a

community that discourage the adoption ofnew ENC practices. For example, in many tra-ditional areas, older relatives such as mothers-in-law still have considerable say over decisionsconcerning pregnancy, birth, and child care. Inmore modern urban communities, their influ-ence may be weaker, while the influence of themass media may be stronger. Similarly, hus-

bands in more traditional areas may dictatetheir wives activities, but this influence maydiminish in some urban areas where women

have greater independence or education.

Cultural constraints refer to cultural pat-terns and beliefs in a community that dis-courage the adoption of new ENC practices.Numerous traditions regarding pregnancyand childbirth are related to religious practice

and reaffirm the important roles and convic-tions of family members. While such prac-tices can certainly be modified, BCC plannersmust appreciate their multifaceted sociocul-tural nature and realize how slow they may beto change.

For example, beliefs in the spiritual

endowment of the placenta can divertattention from and influence immediatecare for the newborn. These beliefs can

become a life or death matter, particularly

Constraints Lines of Inquiry

Informational

Constraints

Determine the degree to which pregnant women and their famlies:

1. Can recognize danger signs and complications

2. Realize the importance of seeking care and know where to seek it

3. Understand hygiene and the need for a clean delivery

Social Constraints

Determine the degree to which:

1. Existing patterns of family authority and responsibility affect the adoption of ENC practices

2.The adoption of ENC practices is contingent upon social approval and/or results in any nega-

tive social consequences

Cultural Constraints

Determine:

1. How concepts of privacy and modesty affect decisions to seek antenatal, intrapartum, or post-

natal care

2. How fatalism, acceptance of God's will, or a sense of political or social powerlessness affects

ENC and care-seeking

3. How beliefs concerning the spiritual nature of the placenta affect the immediate care of the

newborn

EconomicConstraints

Determine the degree to which:

1. Cost is a factor in the choice of delivery attendant or place of delivery; or in decisions to seek

antenatal, intrapartum, or postnatal care or referral care for complications

2. Cost is a factor in practicing clean delivery (i.e., purchase of products such as a clean delivery

kit)

3. Opportunity costs affect antenatal, postnatal, or referral care-seeking or other ENC decisions

(e.g., exclusive breastfeeding)

Supply Constraints

Determine:

1.The extent to which ENC health services and products are available at public health facilities,

on the private market, or in local communities

2. If the quality of these products and services is adequate to attract clients, or at least to not

discourage them

Table 1. All ENC Periods: Constraints and Lines of Inquiry


15/52

Introduction 7

in the first critical moments after birthwhen the newborns risk of asphyxia andhypothermia are greatest.

Concepts of hot and cold are often

related less to temperature than philo-sophical systems. Similarly, attitudestoward hygiene and cleanliness are oftenmore a function of environmental realitythan lack of understanding. The conceptof hygiene in a community without run-ning water, sanitation, fly screens, dustcovers, etc., is quite different from that in

communities with the resources to exer-cise such protective measures.

Economic constraints refer to either unavail-ability of cash or credit to pay for ENCgoods and services, or opportunity cost situ-ations wherein the adoption of a new ENCpractice reduces productivity in other areas.

Lines of Inquiry

Lines of inquiry are simply guidelines for theresearchernot questions to be inserted into aqualitative research questionnaire. They areintended to suggest areas of investigation thatprevious research efforts have found productive.For example, although there may be only one line

of inquiry in the matrix that concerns hygieneand cleanliness (see Table 1), a field investigatorwould be expected to ask a number of questionsabout the issue and would need to probe further:What is the current concept of cleanliness? Howis it affected by environmental conditions? Is theconcept of antisepsis understood?

All lines of inquiry indicated in this guide are evi-

dence-based. That is, research has shown theycan elicit information about behavior, knowl-edge, attitudes, and beliefs that are relevant toENC behavior change. Table 1 includes an amal-gam of many constraints and lines of inquiry forall ENC periods.

Progressive Behavior Change

Perhaps the most important aspect of qualitativeresearch is the concept of progressive change.That is, given the constraints that make behavior

change difficult, to what degree and under whatcircumstances might individuals change?

For example, a family may be severely limitedfinancially and living on the margin in terms ofeconomic productivity. If, as a result, the familyis unable to spare the time or resources for apregnant woman to make the four prescribed

antenatal care visits, encouraging her to attendat least one or two visits may be a viable short-term alternative.

Qualitative researchers need to evaluate whetherthe existing constraints are so severe that changeis not possible, or more commonly, whetherincremental, progressive change may be morefeasible. The question repeated many times

throughout this guideTo what degree andunder what circumstances might current prac-tices be changed?goes to the heart of thisissue, and should be explored for each line ofinquiry presented in the various matrices.

For example, if a pregnant woman states thatafter her last delivery she had not breastfed exclu-

sively, the researcher would pose the question,What would make it easier for you to adopt thispractice? before asking more probing questions,such as, Do you think you could at least not givewater to your newborn? or Would you consid-er increasing the number of times you breastfeedin a day? In short, lines of inquiry should lead

to deeper, core questions regarding ability andwillingness to change.

Behavioral trials, conducted with members of atarget audience in their own community, are par-ticularly effective for assessing the feasibility ofadopting new practices. As extensions of thequalitative research process, behavioral trials


16/52

negotiate possible changes with families (previ-ously identified through in-depth interviews,group discussions, focus groups, etc.) in a real lifesetting. This process can help validate theassumptions made from qualitative research and

in the strategic planning process.

In one study in Bangladesh, qualitative researchdetermined that bathing the newborn on the firstday of life was almost universal. This practice was based on the conviction that an infant isborn unclean and therefore must be cleansedbefore being handled. This perceived uncleanli-

ness has more to do with ritual, tradition, andceremony than with practical, common desires tocleanse the newborn of blood and afterbirth.

BCC planners wondered whether families mightcompromise between current practice and nobathing at all. In a series of behavioral trials usinga doll to simulate possible practices, the plannersidentified a set of new practices that were closerto the ideal andacceptable to trial families. One

of the most successful compromise practices wasgiving a brief sponge bath with warm water, in a warmed room, followed by immediate dryingand wrapping with clean, dry cloths.

Target Audiences

In addition to addressing factors that determine

behavior, qualitative research is also essential foridentifying those individuals who exert the great-est influence on newborn care decisions becausemothers rarely make these decisions on theirown. Although mothers-in-law and husbands areoften cited as the key influentials in ENC familydecision-making, their influence varies according

to local practice, and they are not the sole sourceof authority.

For example, husbands often have the strongestinfluence on economic decisions regarding bothfinancial outlay (e.g., funds for emergency trans-port, purchase of clean delivery equipment) andopportunity cost. A husband, who may be

required by social custom to accompany his wifeon trips outside the family compound or com-munity (e.g., to the health center for ANC), maybe unwilling to give up what he considers to bemore productive labor time.

Traditional healers are another common influ-ence. Though losing authority and respect insome communities as modern media and ideasmake inroads, they remain powerful and influen-tial in more isolated communities.

Overall, an accurate identification of key influen-

tials in a community is best made on the basis ofqualitative research.

Research Methods

Qualitative research is usually conducted usingstandard methodological tools. The two mostcommon are in-depth interviews and focusgroups.

These and other useful methodological tools forqualitative research are discussed in some detailin Chapter 4.

Strategic Planning

An understanding of the informational, social,

cultural, and economic constraints that deter-mine family and community behavior opensthe door to communicating with target popu-lations. Research data are valued most whenthey are used to guide the BCC planner in thedevelopment of BCC campaigns using elec-tronic, print, and other mass media, and/or

interpersonal communication.

As mentioned above, qualitative research canenable the BCC planner to select priority prac-ticesthose leading to the greatest improve-ments in newborn health and survival and whichare amenable to change. As evident in Figure 1(page 3), several ENC practices are recommend-



17/52

Introduction 9

ed, and each one of these practices can be brokendown into sub-practices. For example, interven-tions to promote breastfeeding include: a)encouraging a mother to put her newborn to thebreast immediately, b) encouraging her to avoid

prelacteal or interlacteal feeds, c) encouraging herto feed colostrum, d) helping her to appropriate-ly position the infant at the breast, and e) encour-aging her to continue feeding exclusively through-out the first six months of her infants life.

Based on the data generated from clients, a BCCplanner can make critical decisions concerning

which of the major ENC practices and sub-prac-tices should be considered the highest priorities.

Qualitative research can also enable the BCCplanner to determine the appropriate communi-cation strategy for each selected priority practice.If drying and warming are selected as prioritypractices, how should one work with the commu-nity to promote these practices? To what beliefs,

expectations, and hopes should one appeal?Some communities, such as those in the alti-plano of Bolivia, already warm a room before

birth. That is, they understand the importanceof receiving a newborn in a warm environment.A possible communication strategy to promotedrying, wrapping, or skin-to-skin contact mightbegin with ambient temperature and the con-

cept of warmth as they experience it as adults,and then advance to more thorough practicesfor their newborns.

Qualitative research data can be used to identifyspecific target audiences: influential members ofthe family and community, newborn caregiversand health providers, and pregnant women

themselves. Importantly, qualitative researchcan help program managers design informationand media specifically tailored to these audi-

ences, given their particular roles and responsi-bilities within the family and community. Thestrategies noted above are provided as examplesto illustrate how qualitative research data can betransformed into a BCC strategy. These andother issues relating to the application of quali-

tative research data are explored in some depthin Chapter 5.


18/52

blank


19/52

1.1 What proven, evidence-based

interventions lead to lower neona-tal mortality and morbidity?

Routine ANC visits: Antenatal care is impor-tant, not only for the clinical appraisal of preg-nancy and remedial clinical interventions per-formed by trained professionals, but also for thecounseling and educational services provided forthe benefit of both mother and newborn.

Ensuring proper tetanus toxoid immunization,educating women on the danger signs and com-plications of pregnancy, and preparing them forimmediate, exclusive breastfeeding are particular-ly important. Although their significance varies

geographically, maternal malnutrition, malaria,and reproductive tract infections may adversely

affect newborn health outcomes;5 thus theyshould also be addressed in the context of ANC.Professional counseling by trained staff (and insome cases, trained peer counselors) regarding

issues such as nutrition, hygiene, family plan-ning, preparation for breastfeeding, child devel-opment, minor discomfort during pregnancy,

and danger signs and complications, can also bean effective method for encouraging healthyhousehold practices.

The World Health Organization (WHO) recom-mends at least four ANC visits. However, it is notonly the number of ANC visits that is important;the quality of service and counseling received is

even more important. As mentioned previously

in the introduction, both demand and supplymust be assured.

Recognition of danger signs and complica-

tions of pregnancy: Regardless of whether awoman seeks ANC, it is important that she, herfamily, and her health providers know when,how, and where to seek care from an appropri-

ately skilled professional. Below is a list of pri-ority danger signs and complications duringpregnancy of which everyone should be aware:

Vaginal bleeding

Convulsions (fits)

Loss of consciousness

Severe headaches with or without dizziness

Fever

Difficulty breathing (especially with dizziness

and/or very pale skin)

Contractions/labor pains or water breaking

before 37 weeks gestation

If the mother experiences any of the above,

she should know to seek professional careimmediately, day or night, as these signs couldindicate a life-threatening condition for herand/or the fetus.

Antenatal Care 11

CHAPTER 1: ANTENATAL CARE

EVIDENCE-BASED PRACTICES

1. Pregnant women should make at least

four ANC visits to a health provider

trained in midwifery skills.

2. Pregnant women and their families, as

well as health providers, should be able

to recognize danger signs and compli-cations of pregnancy, and know

when/how to seek appropriate referral

care if needed.

3. Pregnant women, families, and commu-

nities should prepare for birth, includ-

ing their responses to potential mater-

nal and newborn emergencies.


20/52


The mother should also be aware of less seri-ous danger signs that require consultation assoon as possible:

Pale skin

Cloudy urine Foul smelling vaginal discharge Swelling of the face, hands, feet, or legs

Birth preparedness:The third important ante-natal practice for a pregnant woman, her family,

and her community is preparation for the birthand any potential referral care needs. Birth pre-paredness may affect newborn survival by ensur-ing that in the event of serious danger signs andcomplications, not only will they be recognized,

but the mother and newborn will be able to reachan appropriate medical facility in a timely fash-ion, and the family will be able to access andafford quality emergency care. Thus, preparing

for birth consists of several practices:

Selecting a skilled birth attendant6

Selecting a health facility to go to if the moth-er or newborn experience complications

Identifying and assuring emergency trans-portation to a health facility

Setting aside sufficient money to pay foremergency transportation and medical care

1.2 What are the current prac-

tices, and to what degree or under

what circumstances might they be

changed?

Identifying current newborn care practices is thefirst step in preparing a foundation for the design

and development of a BCC program. Under-standing the degree to which women and theirfamilies would be willing to accept new practicesand change their current behaviorthat is, whatchanges they would make and under what condi-

tions they would make themis essential to craft-ing realistic, relevant behavior change messages.

Qualitative research should first investigate prac-tices currently performed during pregnancy rela-tive to the evidence-based practices listed above:Do women go for ANC? When and how fre-quently? What is the content of these visits? Can

they and their families recognize danger signsand complications during pregnancy? Do fami-lies adequately prepare for birth and anticipatethe possibility of an emergency?

Recognizing danger signs and complications canbe a problematic line of inquiry for the qualita-tive researcher, due to the subjective nature of

many symptoms. For example, in communities where diarrhea, malaria, or upper respiratoryinfections are common and frequent, a fever may

be overlooked or disregarded and its significanceinaccurately gauged. Difficulty breathing is alsosubject to local interpretation, particularly in thepreterm infant or in the presence of frequentrespiratory infections or environmental pollutionand dust. Therefore, it is important not only to

find out what people claim to know and recog-nize, but also to ascertain the depth and accuracyof their knowledge. Identifying and using thelocal terms for commonly recognized dangersigns can also be essential for eliciting andrecording accurate responses.

The second step for qualitative research should

be to determine what it would take for families toadopt more positive behaviorshow and towhat degree could the current practices be mod-ified? Based on an understanding of the informa-tional, social, cultural, economic, and supply con-straints, good researchers may be able to inferwhat changes are feasible. However, it is only by

probing prospective behavior that one can deter-mine the real degree of change that might be

acceptable and achievable.

For example, if a woman states that she does notseek ANC because of economic constraints, shemight reconsider attending just one antenatal


21/52

Antenatal Care 13

visit instead of four. Similarly, another womanmight be unwilling to seek ANC more than oncebecause of cost, but she might agree if the visitcould be made at home. She might also agree topay for ANC visits if she perceived the quality of

service to be better. Overall, although familiesmay not be willing or able to take allrecommend-ed birth preparedness measures, they might bewilling to take someof them. An understanding ofthe positive potential for progressive behaviorchange, in addition to an understanding of thenegative constraints on behavior change, isessential to the crafting of effective BCC strate-

gies and messages.

Table 2 lists priority practices of the antenatal

period and several corresponding lines of inquirythat researchers may want to address to deter-mine the current level of compliance with evi-dence-based practices.

1.3 What factors limit or discour-

age peoples ability and willingness

to practice evidence-based ENC?

There are four major categories of demandconstraints that affect ability and willingness tomove from existing newborn care practices to

the evidence-based ENC practices recom-mended by SNL:

Informational constraints: a simple lack ofinformation, knowledge, or experience need-ed to make informed ENC choices

Social constraints: patterns of family and

community authority, roles, and responsibilities

Cultural constraints: religious beliefs or tra-ditional rituals and other practices

Current Practices Lines of Inquiry

Routine ANC Visits

Determine:1.Whether pregnant women currently receive any ANC

2. If they do, where and from whom they receive it

3.The timing and frequency of these visits

4.The procedures performed and counseling provided during these visits

5.What would facilitate an increased number of visits

Recognition of Danger

Signs and Complications of

Pregnancy

Determine:

1.When respondents feel that mother or newborn are in danger during pregnancy, and the

local terms for these symptoms of illness

2.What their responses would be to these symptoms

3.The health provider or facility to which they would go to seek care for these symptoms

4.Which danger signs/complications are generally perceived or recognized as such; and

which ones are not recognized, misperceived, or misinterpreted

Birth Preparedness

Determine if pregnant women and their families:1. Select a skilled birth attendant to assist at delivery

2. Prepare for emergencies that might occur during pregnancy, labor, or delivery

3. Identify a particular health facility to go to in case of an emergency

4. Identify emergency transportation

5. Set aside funds for emergency care and transportation

6.What would facilitate 2-5, above

Determine:

1. If there is a community fund for use in maternal or newborn emergences

2. If so, how families gain access to this fund

Table 2. Antenatal Period: Lines of Inquiry about Current Practices


22/52


Economic constraints: deficiency of individual, family, or community resources,translating into lack of access to healthgoods and services

Some of the issues meriting particular attentionin the antenatal period include:

ANC visits and economic constraints:

Although the concept of financial cost will beeasily understandable to families and field inter-viewers, the concept of opportunity cost may notbe. In fact, it is likely to be far greater than any

cash outlay. Field investigators must be aware ofthis factor and probe for relevance. Male familymembers, for example, may not wish to accom-

pany their wives to the clinic simply because theydo not feel they can lose a valuable morning orday of work.

Knowledge and understanding of danger

signs and complications: Assessing family

members knowledge on this topic is not astraightforward task. It is complicated by the sub-jectivity of many of the symptomsincludingtheir contextand the various local terms usedto describe them. Bleeding, for example, may beconsidered natural and normal during pregnancy,as some spotting is quite common. Similarly, theexpression difficulty breathing may simply be

applied to a bad cold or congestion during a verydusty, windy time of year. Therefore, interview-ers must be trained to probe carefully to ensure

that local terms are identified, the local context isunderstood, and the respondents answer as clear-ly as possible. Interviewers should determine onlywhether peoples knowledge conforms to the clin-icaldefinitions used by the researcher. Finally, it is

important to explore prospective responses tosymptoms; specifically, from whom and underwhat circumstances help is sought.

Birth preparedness:While health professionalsunderstand implicitly the need for emergencypreparation, many local residents may not appre-ciate its importance. This is due not only to infor-

mational constraints, but also to cultural percep-tions of risk, destiny, or fate, and economic per-ceptions of power. That is, the cost of preparing

for an emergency for middle class urban familiesmay be considered relatively small compared withthe benefits. This is not likely to be true for poorrural families living on the economic margins.Similarly, middle class urban audiences may havegained a certain confidence in public and private

health facilities, believing that they can in factimprove health outcomes, while poorer familiesmay believe that they are better off caring for themother and newborn at home. In short, while theconcept of birth preparedness seems simple andstraightforward, current practices may be inti-mately linked to subtle informational, social, cul-tural, and economic factors.

Table 3 provides lines of inquiry that have provenfruitful in research on antenatal care practices.


23/52

Antenatal Care 15

Consraints Lines of Inquiry

Informational Constraints

Determine whether pregnant women and their families:

1. Know the benefits of seeking ANC

2. Understand the importance of attending ANC more than once

3. Understand the importance of proper home care during pregnancy

4. Understand the importance of preparing for a maternal or newborn emergency

5. Understand the relationship between danger signs and complications during

pregnancy and maternal and neonatal mortality and morbidity

6. Understand the relationship between proper care during pregnancy and positive

birth outcomes

Social and Cultural

Constraints

Determine:

1.The necessity of having an accompanying male relative

2. Privacy or modesty concerns about disrobing in the presence of a health

provider

3. Other religious or cultural rituals or beliefs

4. Perceptions of service quality

Economic Constraints

Determine if cost is a factor in:1. Selection of health providers

2.ANC attendance

3. Setting aside of emergency funds for transportation and care

Transportation ConstraintsDetermine if the availability of transportation affects ANC attendance or emer-

gency care planning

Time Constraints Determine how other obligations (e.g., work, childcare) affect ANC attendance.

Influence of Decision-Makers

Determine:

1.The most influential family or community members for each major antenatal

practice

2.Whether their influence is positive or negative (i.e., how or to what extent the

influential party encourages or discourages evidence-based practices)

3.What influence pregnant women have, if any, over decisions concerning care dur-ing pregnancy

Table 3. Antenatal Period: Lines of Inquiry about Constraints


24/52

blank


25/52

Intrapartum Care 17

2.1 What proven, evidence-based

interventions lead to lower neona-tal mortality and morbidity?

Skilled attendance at delivery: The impor-

tance of this aspect of intrapartum care has beenwell documented historically. However, at pres-ent only about half of all women in developing

countries deliver with a skilled attendant. Whena skilled attendant is not yet available, trainedcommunity-based birth attendants can helpimprove newborn health and survival.Incorporating community-based health providersin maternal and neonatal health programs should

be accompanied by strengthening the links alongthe household to the hospital continuum of care,including a long-term plan for training and pro-viding sufficient skilled attendants. All SNL pro-grams focus on strengthening the midwifery

skills of birth attendants, whether at health facil-ities or in the community, to provide counseling,conduct clean and safe deliveries, recognize dan-

ger signs, take appropriate action to help bothmother and newborn survive, and refer compli-cated cases to a higher level of care as needed.

Recognition of danger signs and complica-

tions of labor and delivery: As with antena-tal care, the second aspect of intrapartum care

critical to the survival and well-being of moth-er and newborn is the ability to recognize whento seek referral or emergency care from anappropriately trained professional. Below is alist of priority danger signs and complicationsof the intrapartum period of which everyoneshould be aware:

Bleeding

Convulsions (fits) Loss of consciousness

Prolonged labor >12 hours

Preterm labor

Prolapsed cord or noncephalic presenting part

Meconium discharge during labor

Fever

Because a woman in labor may not be able toassess her own risk, it is important that the birth

attendant immediately recognize and appropri-ately manage or arrange referral care for dangersigns and complications. Therefore, qualitativeresearch should be designed to assess the knowl-edge and understanding of mothers, their fami-lies, and birth attendants.

The birth preparations recommended in theantenatal period (identifying a referral facility,securing emergency transport, and setting aside

emergency funds) play their most critical role in

the intrapartum period. These measures canexpedite transfer of the mother and newborn inan emergency, thereby saving lives.

Clean delivery: Newborns are also more likelyto survive if the delivery is cleanthat is, if

CHAPTER 2: INTRAPARTUM CARE


1. A skilled birth attendant should

assist at the delivery.

2. Pregnant women and their families, as

well as birth attendants, should be able

to recognize danger signs and compli-

cations of labor and delivery, and

know when/how to manage or seek

appropriate referral care if needed.

3. All deliveries should be clean to pre-

vent infection.


26/52


actions are taken to help prevent infection. Just aspreparing for birth consists of several practices,ensuring a clean delivery also is comprised of aset of sub-practices. A clean delivery means:

All those attending to the mother or new-born wash their hands with soap and waterbefore, during, and after delivery

Perineal area is washed before each examina-tion and before delivery, and nothing foreignis put into the vagina (i.e., nothing but theexaminers hand, and only when necessary)

Delivery surface is clean or, at a minimum,the birth does not occur on the bare floor

or ground

2.2 What are the current prac-



changed?

Again, the first step for qualitative research is toinvestigate the practices currently followed duringthe intrapartum period in relation to the evidence-based practices listed above. Second, the researchmust determine the degree to which and under

what conditions behavior change would be accept-able and feasible. This helps to ensure the design ofa BCC program that is both realistic and relevant.

Thus, qualitative research should first obtain

information about the practices and procedurescurrently followed during labor and delivery:Who is present at what times during labor and

delivery? What do they do to assist the birth?Can they recognize danger signs and complica-


Skilled Attendance atDelivery

Determine:

1.Whether pregnant women use a skilled attendant for delivery

2.Where pregnant women deliver, whether at home or at a health facility3.Who attends to the needs of mother and newborn during labor and delivery

4. If a family would consider using a skilled birth attendant for delivery, and what would

make this decision easier and/or the practice more acceptable or feasible

Recognition of Danger Signs

and Complications of Labor

and Delivery

Determine:

1.When respondents feel that mother or newborn are in danger during labor and deliv-

ery, and the local terms for these symptoms of illness

2.What their responses would be to these symptoms

3.The health provider or facility to which they would go to seek care for these symp-

toms

4.Which danger signs/complications are generally perceived or recognized as such; and

which ones are not recognized, misperceived,or misinterpreted

Clean Delivery

Determine:

1.Whether those attending to mother or newborn wash their hands with soap andwater before, during, and after delivery

2. On what surface women deliver, whether it is cleansed with soap and water or other

traditional materials, and whether it is cleansed more than once during labor and

delivery

3.Whether the perineal area is cleansed before vaginal examinations and delivery

4.What would make these decisions about cleansing easier and the practices more

acceptable or feasible

5.Whether anything foreign is put into the vagina, and under what conditions this prac-

tice might be discontinued

Table 4. Intrapartum Care: Lines of Inquiry about Current Practices


27/52

Intrapartum Care 19

tions during delivery, and what are theirresponses to these? Are clean delivery proce-dures followed?

With regard to recognizing danger signs and

complications, it is again important to find outnot only which symptoms are known and recog-nized, but also the depth and accuracy of thisknowledge and what actions they would promptin response. It is also important to understandhow birth attendants respond to danger signs orcomplications during delivery.

After identifying current practices, qualitativeresearch should then determine what it wouldtake for the adoption of evidence-based prac-

tices. If a pregnant woman does not practiceclean delivery, what might make such changesmore acceptable or feasible? Under the currentcircumstances, what would be the most appropri-ate degree of change to promote? For example,although families might consider it awkward or

cumbersome to have the birth attendant washher hands during delivery, they might accept themore important practice of washing immediatelybefore. If they feel that physical cleaning of thedelivery surface is all that is required (i.e., no spe-cial birthing cloth or plastic) and are unwilling tochange, they might consider the more importantuse of a clean blade and tie for cord care.

Table 4 (page 20) lists priority practices of theintrapartum period and several correspondinglines of inquiry that researchers may want toaddress to determine the current level of compli-ance with evidence-based practices.

2.3 What factors limit or discour-age peoples ability and willingness


As with antenatal care, a variety of informational,social, cultural, economic, and other factors con-

dition peoples ability and willingness to changeintrapartum care practices. When investigatingthese constraints, there are a number of impor-tant issues that must be addressed for the intra-partum period. Some which merit particular

attention include:

Birth attendants: While the advantages ofskilled birth attendants may be obvious to pro-fessionals, families, influenced by norms of tradi-tion, trust, friendship, and privacy, often have adifferent perspective. They may also be suspi-cious of letting outsiders into personal mat-

ters, and may rightly conclude that a skilled birthattendant will cost more. Qualitative research,therefore, must probe the depths of these con-

victions, and determine whether and under whatconditions the use of birth attendants mightbecome more acceptable or realistic.

Concepts of privacy and modesty: In soci-eties where these concepts are highly valued for

women, families may not choose birth attendants who require that they undress (as may berequired by many doctors and nurses) or mayavoid facilities where they would be in the pres-ence of strangers.


signs and complications: Determining knowl-

edge of danger signs and complications is com-plicated by the local terms and context, as well asby the subjectivity of many of the symptoms.Interviewers must probe carefully to ensure thatresponses are clear and accurately interpreted;they must be trained to assess only whetherknowledge conforms to the clinicaldefinitions of

the symptoms.

Clean delivery: This is a complex subjectbecause it is comprised of several sub-practices;researchers will have to explore each one careful-ly. For example, hand washingbeforedelivery mayseem logical and immediately understandable to


28/52


skilled health providers, but may not be so totrained birth attendants and families who areoften used to hand washing after delivery.Similarly, while there may be many families whowould consider hand washingbeforedelivery, they

may find it awkward or inconvenient to wash fre-quentlyduringdelivery.

Traditional concepts of cleanliness and

hygiene: In many cases, local or traditional atti-tudes underlie decisions concerning clean deliv-ery; thus researchers should address these.

Perhaps most importantly, many families may notbe aware or understand that using soap and copi-ous amounts of water can help prevent infec-tions. They also may not possess the financialresources to buy soap or may not have easy

access to clean water, particularly if it must becarried from afar or has a high economic value.

Table 5 provides lines of inquiry that haveproven fruitful in previous research on intra-partum care practices.


Informational

Constraints

Determine if pregnant women and their families:

1. Understand the importance/benefits of using trained/skilled birth attendants

2. Understand the relationship between danger signs and complications during labor and delivery and

maternal and newborn mortality and morbidity

3. Understand the importance of washing hands with soap and water before, during, and after delivery

4. Know the benefits of delivering on a clean surface

Determine:

1.What benefits or harm are perceived to result from putting foreign objects into the vagina

2. Families' perceptions about the availability of emergency care, and the quality and cost of that care

3.Why women say they do not give birth on a clean surface

Social and

Cultural

Constraints

Determine:

1.The common perceptions of "clean" and "dirty" (e.g., of hands, of instruments used during delivery, or

of the surface on which the woman gives birth)2.The common definitions of a clean/dirty environment

3.The perceptions of a link between cleanliness and infections, if any

4.The degree to which poor facility attendance is influenced by perceived low quality of service and

attention

Determine to what degree the following inhibit choosing a birth attendant/institutional birth:

1.The necessity of having an accompanying male relative

2. Privacy/modesty - concerns about disrobing before a health provider

3. Other religious or social rituals or beliefs

4. Unacceptable/unfamiliar practices

Economic

Constraints

Determine:

1.The extent to which cost influences the choice of delivery attendant or place of delivery (home or

facility)

2.Whether families feel that they have access to and can afford the supplies they need to ensure clean

delivery (e.g., soap and water, cloths or towels)

Transportation

Constraints

Determine how, if at all, transportation issues affect the choice of delivery attendant or place, or care-

seeking for danger signs and complications.

Influence of

Decision-

Makers

Determine:

1.The most influential family or community members for each major practice listed above

2.Whether their influence is positive or negative (i.e., how and to what extent the influential party

encourages or discourages evidence-based practices)

3.The extent to which pregnant women have influence, if any, over decisions concerning care during

labor and delivery

Table 5. Intrapartum Care: Lines of Inquiry about Constraints


29/52

Postnatal Care 21

3.1 IMMEDIATE NEWBORN CARE

3.1.1 What proven, evidence-based

interventions lead to lower neona-

tal mortality and morbidity?

Drying and warming:A newborn regulates hisor her body temperature much less efficiently

than an adult, and loses heat more easily, espe-cially from the head. To prevent hypothermia,the newborn should be thoroughly dried with aclean cloth or towel as soon asthe head and bodyare fully delivered and beforethe placenta is deliv-ered. Besides limiting loss of body heat, the stim-ulation this provides can promote breathing andaid an asphyxiated newborn.

The newborn should then be wrapped, includingthe head, with a clean and dry cloth or towel. Inaddition to immediate wrapping, the newbornswarmth should be ensured after delivery throughcontact with the mother, especially for infantswith a low birth weight.

There are two possible practices in this regard:

Lay the newborn on the mothers abdomen,

with the mothers skin touching the new-borns skin (skin-to-skin contact, alsoreferred to as Kangaroo Mother Care). Coverboth newborn and mother with a clean anddry cloth, towel, or blanket.

If skin-to-skin contact is not possible, lay thewrapped newborn on the mothers abdomen

or next to the mother on a clean and dry

cloth, towel, or blanket. Cover the newbornand keep him or her covered with anotherclean and dry cloth, towel, or blanket.

Bathing the newborn is generally not necessaryon the first day, and should be postponed untilthe infant is stableat least six hours, butpreferably no earlier than 24 hours after birth.

The bathwater and the room should be heatedwhen bathing.

Ensuring breathing:The newborn that, despitethe stimulation provided by vigorous drying, hasnot cried, is not breathing regularly, or is gaspingone minute after birth, needs immediate inter- vention. The skilled birth attendant should be

equipped and prepared to perform resuscitation,preferably by bag-and-mask.

Immediate breastfeeding:The newborn shouldbe breastfed within one hour after birth, and

should be fed only breast milk (see section 3.2).

Clean cord care: Clean cord care practices arecrucial to prevent infection. The umbilical cord

should be cut with a clean (boiled) blade and tied with clean (boiled) materials. No substancesshould be put on the stump.

CHAPTER 3: POSTNATAL CARE


1. Newborns should be thoroughly dried

immediately after delivery and kept warm.

2. Newborns should be observed for cryingand breathing immediately after delivery;

asphyxiated newborns should be recognized

and resuscitated.

3. Newborns should be immediately breastfed.

4. Cord care procedures should be clean.


30/52


3.1.2 What are the current prac-



changed?

As in the first two chapters, the first task for qual-itative research is to elicit information about what

people currently do to care for the newbornimmediately after delivery. Specifically, thesequence of immediate newborn care should beexplored: What is done to dry and warm the new-born, and when is this done in relation to deliveryof the placenta? When and how is breathingassessed and ensured? How is the cord cut and

cared for? When is the newborn first breastfed?Second, the researcher must determine what itwould take for the adoption of evidence-basedENC practices. For instance, although keepingwarm is a natural human instinct, the newborns

high risk of hypothermia and the consequentneed for special attention to his or her warmthmay not be well understood. Probing questionsshould be asked to determine what steps familiesmight take to give their newborns added thermalprotection. Might they consider drying the new-born beforedelivery of the placenta, providing atleast a light covering, and keeping the infant in

contact with the mother or another caregiver?


Drying and

Warming

Determine:

1.Whether newborns are dried and wrapped immediately after birth, and before delivery of the

placenta

2. If so, how and with what materials

3. If not, whether families would consider drying/wrapping the baby immediately after delivery, and

what might facilitate this

4.Where the newborn is placed immediately after delivery; before and after delivery of the

placenta and after drying, and for how long

5.Whether the newborn has skin-to-skin contact with the mother

6. If not, whether families would consider it possible to put the newborn immediately againstmother's skin/body

7.What would make this practice (or modifications of it) more acceptable or feasible

8.Whether the newborn remains with the mother immediately after delivery, and if separated, how

soon after birth and for how long

9. How soon after delivery the newborn is first bathed and by whom (e.g., family member, birth

attendant, etc.)

10. If it would be acceptable to delay bathing until the second day of life, if not longer

11.The temperature of the bath water and the room during bathing

Ensuring Breathing

Determine:1.Whether and when attention is given to assessing the newborn's cry and breathing, and who

makes this assessment

2.What signs of breathing are assessed

3.What is done for the non-breathing newborn, by whom, and for how long4. If breathing is not assessed (and assisted, if necessary) immediately after birth, what might

facilitate this

Clean Cord Care

Determine:1.What instruments/materials are used to cut and tie the cord

2.What measures, if any, are taken to clean these instruments (e.g., if they are boiled)

3.What might facilitate the use of clean instruments for cord care

4.What substances, if any, are applied to the cord stump and by whom

5.The frequency and duration of this treatment

6.Whether it would be acceptable to simply keep cord stump clean and dry, and apply nothing

Table 6. Immediate Newborn Care: Lines of Inquiry about Current Practices


31/52

Postnatal Care 23

Table 6 lists priority practices of the immediatepostnatal period and several corresponding linesof inquiry that researchers may want to pursue todetermine the current level of compliance withevidence-based practices.

3.1.3 Which factors limit or dis-

courage peoples ability and will-

ingness to practice evidence-

based ENC?

When investigating constraints on immediatenewborn care, there are a number of importantissues that must be addressed. Those warrantingparticular attention include:

Concept of warmth:While warmth appears tobe a basic human concept, in reality there can be

many subjective versions of warmth. Membersof the same household often disagree on themost comfortable temperature. The elderlyoften feel cold more intensely than the young.On the subject of ENC, many women whoexperience a shiver reflex immediately afterbirth draw the conclusion that their bodies andskin are colder than those of the newborn, andthus refuse skin-to-skin contact. It is critical for

investigators to gauge indigenous perceptions ofwarm and cold to create accurate and effectiveBCC messages of drying and warming.

Concept of the spiritual endowment of the

placenta:While most Western cultures view theplacenta as essential to the growth and survivalof the fetus while in the womb, but of no value

after birth, many other societies believe it is

endowed with a spirit. Because of this separatespiritual identity, and also because of fears insome societies that the undelivered placenta maymove upwards in the chest and choke thewoman, the delivery of the placenta is oftenconsidered as important as that of the newborn,

and of even greater urgency. Consequently, moreattention is often paid to the delivery of the pla-centa than to the newborn. At the same time,because spiritual identity also means that thenewborn and the placenta are equal beings at

birth, mothers and caregivers should be able toaddress the immediate needs of the newborn. Inany case, this subtle and often profound beliefhas important ramifications for ENC behaviorchange and must be carefully explored.

Concepts of hygiene and cleanliness:

Hygiene and aseptic conditions may be unknown

or very difficult to achieve in many poor commu-nities. People may be unaware of the environ-mental dangers of infection, and may be unable

to do much to combat them. This pervasiveacceptance of unhygienic conditions may extendto cord care, newborn drying and wrapping,materials, etc.

A related issue may arise in those cultures where

birth is considered polluting; in this situation,laying the newborn against the mothers skin ordelaying bathing may be considered dangerous.Moreover, these practices may be a violation ofreligious beliefs, perceived as compromising thereligious standing of those who have contactwith the polluted infant. There may also besociocultural reasons why families do not prac-

tice clean cord care; they may believe that apply-ing certain substances on the cord helps it toheal, when in fact, this practice increases therisk of infection. Often there is a religious orcultural significance to the application of cer-tain substances.

Table 7 lists priority practices of the immediatepostnatal period and several corresponding lines

of inquiry that researchers may follow to deter-mine the current level of compliance with evi-dence-based practices.


32/52



Informational

Constraints

Determine to what degree pregnant women, their families, and birth attendants:

1. Understand the importance of immediately drying and warming the newborn

2. Understand the importance of ensuring that the newborn is breathing, and if so, if they knowhow to stimulate breathing

3. Know the benefits of clean cord care, and understand the consequences of putting

nothing/putting certain substances on the cord

4. Understand the effects of bathing the newborn immediately, and the benefits of delaying

bathing

5. Understand the importance of warming the room and water for bathing

Social and Cultural

Constraints

Determine:

1.Whether the placenta is believed to be endowed with any spiritual nature and how this con-

cept affects the relative way the newborn is regarded and the attention given him/her imme-

diately after birth

2.Whether people think that what they do (e.g., to dry and warm the newborn, establish

breathing, care for the cord in a clean manner, delay bathing) can have any impact on a new-

borns survival, and how

3.To what extent people feel that they can control whether their newborn lives or dies4.Whether some people may consider it better for a newborn to die than to live, and if so

why

5.Whether the belief that certain negative practices (e.g., not drying or attending to the new-

born immediately after birth) are important to determine whether the infant is fit to survive

6.What effect religious beliefs, such as ritual pollution, have on immediate newborn care, par-

ticularly with regard to bathing


Determine whether families can afford clean materials to dry and warm the newborn, to cut the

cord, and to provide a warm bath (e.g., warm water, clean towels or cloths that have been

washed in soap and water, a heating source for bath water, a heating source for the room).

Influence of Decision

Makers

Determine the most influential members of the family and the community concerning the ENC

practices discussed above.

Other Constraints

Determine:

1. People's definitions of "dirty and clean" (e.g., materials used for labor and delivery,

hands/body parts, the instruments used during the delivery)

2.Whether people believe they can and should improve the hygiene and/or cleanliness of their

household environment, and to what extent economic or environmental factors are con-

straints

3. If there are certain conditions that cannot be changed

4.When a cloth/instrument is considered "clean" and when a cloth/instrument is considered

"dirty"

5. How, if at all, the occurrence of a maternal complication affects newborn drying and warm-

ing, establishment of breathing, cord cutting and care, and bathing practices

Table 7. Immediate Newborn Care: Lines of Inquiry about Constraints


33/52


34/52


35/52

Postnatal Care 27

breastfeeding does not provide adequate fluid.However, a number of breastfeeding promotionprojects have been successful in encouragingmothers to discontinue the practice of givingwater to newborns, at least during cooler times of

the year.

Qualitative research should also explore possibil-ities for behavior change negotiation on the issueof prelacteal feeding. Prelacteal feeds, such ashoney, tea,ghutti, or sugar water, can be harmful,as they may cause infections and diarrhea. Therisks of this ritual are even more serious if sub-

stances (like honey) are routinely given a numberof times as an interlacteal feed.The goal of qualita-tive research in these situations is to determine if

there are conditions under which a family mightagree to reduce the amount and frequency ofprelacteal feeds. Limiting the practice to theanointing of the newborns lips, rather than actu-ally introducing the food itself, might also be afeasible compromise in some cultures.

Table 8 lists priority practices of the neonatalperiod and several corresponding lines of inquirythat researchers may want to address to deter-mine the current level of compliance with evi-dence-based practices.

3.2.3 What factors limit or discour-

age peoples ability and willingness


For neonatal care, as with the previous ENCperiods, a variety of informational, social, cultur-al, economic, and other factors can affect peo-ples ability and willingness to change to evi-dence-based practices. When investigating these

constraints on neonatal care, there are a numberof important issues that must be addressed.Those meriting particular attention include:

Colostrum: Many societies reject feeding thenewborn a mothers colostrum, despite the nutri-

tional and immunological properties that it pos-sesses. In many cultures, colostrum is consideredan unclean substance that must be extruded (dis-carded) before the milk can be fed. Others con-sider it a purgative, and still others believe it to be

a neutral, but non-nutritive cleansing substance.It is important for the researcher to determinethe convictions that families have regardingcolostrums negative properties, as well as thedepth of these beliefs. In other words, in societiesthat believe colostrum to be simply a neutral, non-nutritive substance, changing practices may bemuch easier than in those societies that think it is

a purgative. In areas where immunization pro-grams are already well accepted,likening colostrum to the infants first immuniza-

tion may be an effective behavior change message.

Prelacteal feeds:Prelacteal feeds are consideredan important social and cultural custom that, likemarriage, confirmation, and circumcision, conferspecial importance on certain family members

and confirm their role and responsibilities withinthe family. In some cultures, prelacteal feeds arereligiously significant, the practice seen asbestowing Gods protection upon the newborn. While it is is, consequently, particularly difficultto eliminate, it may be possible to modify thepractice, retaining its traditional ritual valueswhile reducing the adverse health risks (see for

instance, the Hausa ritual, described on p. 4-5).

Breastfeeding and economic factors/oppor-

tunity costs: One of the greatest obstacles toexclusive breastfeeding can be the opportunitycost of the practice. While some BCC programshave portrayed breastfeeding as a no-cost option,

in reality that is far from the case. Breastfeedinga newborn 8 to 10 times a day, which is usual in

on-demand feeding cycles, represents a distincteconomic cost whether a woman works within oroutside the home. In modernizing urban soci-eties where women work in the organized sector,exclusive breastfeeding may represent an oppor-tunity cost that is simply too great to bear.


36/52


Similarly, in more traditional societies wherewomens domestic labor is arduous and continu-ous, time taken for breastfeeding reduces otherproductive work. Therefore, the decision not tobreastfeed is a logical one when the perceived

economic benefits of labor exceed the perceivedadvantages of breastfeeding. Qualitative researchersshould investigate the economic ramifications ofbreastfeeding and determine whether economi-

cally productive women could increase the fre-quency of breastfeeds.


signs and complications: Although the new-

born danger signs and complications listed previ-ously may appear obvious to the experiencedhealth professional, they are, in fact, somewhatsubjective and open to local interpretation. It iscritical that when performing qualitative

research, interviewers define local terms andcontext for various illnesses and signs of illness,and agree upon minimum criteria to accept asrecognition of each danger sign.

Table 9 suggests areas of investigation that havebeen productive in former research on neonatalcare practices.


Informational

Constraints

Determine the perceived positive or negative effects of:

1. Giving colostrum to the newborn

2. Giving only breast milk

3. Putting the newborn to breast within an hour of delivery

Determine whether mothers believes:

4.Their breast milk provides sufficient food and liquid

5.Their breast milk supply is adequate in the first month

Social and Cultural

Constraints

Determine:

1. Common perceptions of colostrum: whether it is considered dirty, a purgative, a non-nutri-

tive precursor to breast milk, etc.2.Whether there are any rituals in which substances are given to the newborn, and for what

reasons

3.Whether keeping the newborn with the mother is perceived as important, and if not, why

4. How belief in the spiritual endowment of the placenta affects the timing of first breastfeed-

ing (i.e., do women wait for the placenta to be delivered)

5.Whether families realize that breastfeeding helps stimulate delivery of the placenta and

limit the risk of postpartum hemorrhage

6.Whether the mothers age or the newborns birth order or sex is a factor in breastfeeding


Determine:

1.Whether women's economic opportunities, at home or outside the home, interfere with

exclusive breastfeeding

2.Whether women believe that their diet or inadequate food availability influence the quanti-

ty/quality of breast milk

Time Constraints

Determine whether mothers perceive exclusive breastfeeding in the first month to be more

or less time consuming than other feeding alternatives, and what effect, if any, this may have on

feeding behavior

Table 9. Neonatal Care: Lines of Inquiry about Constraints


37/52

Research Methods 29

4.1 Overview

The previous chapters of this guide provide linesof inquiry to investigate current ENC practicesand the various constraints limiting ENC behaviorchange. Actual field research may be designed andimplemented on the basis of these lines of inquiry.

There are many different qualitative researchmethods available, ranging from those that arewidely applicable, such as focus groups, to more

specific, but equally useful techniques, such as

mapping. The choice of methods depends onmany factors. The two most commonly usedqualitative research methods follow:

Focus groups are best used to probe a com-plex, narrowly focused issue. A topic thatinvolves cultural and religious beliefs and prac-

tices, for example, may require the patient, delib-erate, participatory techniques that characterizefocus groups. A topic such as exclusive breast-feeding, which is conditioned by a number ofsocial, cultural, and economic factors, also lendsitself to focus group discussions.

Focus groups are usually comprised of 8 to 12persons of similar background. A skilled facilita-

tor guides the discussionprobing beliefs andattitudes underlying the topic of interestwhilemembers of a study team may record answers.

Individual or group interviews are often used

when factual information needs to be collected,such as the current practices of health personnel.It may be more efficient to collect this informa-

tion from a number of workers gathered in oneplace than to interview them individually. Agroup of health workers may be asked, for exam-ple, Why did you want to become a communityhealth worker?

In a group interview, all respondents are inter-

viewed and urged to respond. No attempt

Documents

Qualitative Research to Improve Newborn Care Practices