Exploring the shift in newborn care practices among mothers and grandmothers in rural Odisha, India - a qualitative study.

BACKGROUND: This study delves into newborn care and infant-feeding practices in rural Odisha, specifically focusing on the rural KBK + region of Odisha (Kalahandi-Bolangir-Koraput region), inhabited predominantly by Schedule Tribes and Schedule Castes individuals. There has been an improvement in the health indicators in these areas in recent times. In the background of improved health indicators in these areas, this research explores the current and changing newborn care practices and attempts to gain insight into people's perceptions of the factors that brought about the changes. METHODS: This qualitative study was conducted between February and July 2023 at Christian Hospital, Bissamcuttack in Odisha. The methodology involved focused group discussions with mothers and grandmothers. RESULTS: Analysis revealed healthy practices like exclusive breastfeeding till six months of age, appropriate timing of the first bath, and prompt healthcare-seeking behavior for minor illnesses among the mothers. The use of cow ghee or breast milk in a baby's eyes, the application of ash on the umbilical cord, and the use of herbal medicines for minor illnesses were practiced more by the grandmothers in the past and were not as popular among the mothers. It is noteworthy that the cultural practices to ward off the 'evil eye' were practiced by both mothers and grandmothers alike. Despite the influence of traditional cultural practices on the beliefs and norms of the community, the study identified a shift in health-seeking behavior, with increased reliance on healthcare providers and safe healthcare practices. The study identifies the pivotal role of Accredited Social Health Activists (ASHAs) as a bridge between the rural communities and the healthcare system. CONCLUSIONS: This research provides valuable insights for healthcare providers aiming to enhance community-centric safe newborn care practices in rural settings. The emphasis is on the importance of understanding the current and changing local practices. This would help the healthcare providers to encourage healthy practices while eliminating the harmful practices related to newborn care through community workers like ASHA and Anganwadi workers.

Evaluation of an obstetric and neonatal care upskilling program for community health workers in Papua New Guinea.

BACKGROUND: 60% of women in Papua New Guinea (PNG) give birth unsupervised and outside of a health facility, contributing to high national maternal and perinatal mortality rates. We evaluated a practical, hospital-based on-the-job training program implemented by local health authorities in PNG between 2013 and 2019 aimed at addressing this challenge by upskilling community health workers (CHWs) to provide quality maternal and newborn care in rural health facilities. METHODS: Two provinces, the Eastern Highlands and Simbu Provinces, were included in the study. In the Eastern Highlands Province, a baseline and end point skills assessment and post-training interviews 12 months after completion of the 2018 training were used to evaluate impacts on CHW knowledge, skills, and self-reported satisfaction with training. Quality and timeliness of referrals was assessed through data from the Eastern Highlands Province referral hospital registers. In Simbu Province, impacts of training on facility births, stillbirths and referrals were evaluated pre- and post-training retrospectively using routine health facility reporting data from 2012 to 2019, and negative binomial regression analysis adjusted for potential confounders and correlation of outcomes within facilities. RESULTS: The average knowledge score increased significantly, from 69.8% (95% CI:66.3-73.2%) at baseline, to 87.8% (95% CI:82.9-92.6%) following training for the 8 CHWs participating in Eastern Highlands Province training. CHWs reported increased confidence in their skills and ability to use referral networks. There were significant increases in referrals to the Eastern Highlands provincial hospital arriving in the second stage of labour but no significant difference in the 5 min Apgar score for children, pre and post training. Data on 11,345 births in participating facilities in Simbu Province showed that the number of births in participating rural health facilities more than doubled compared to prior to training, with the impact increasing over time after training (0-12 months after training: IRR 1.59, 95% CI: 1.04-2.44, p-value 0.033, > 12 months after training: IRR 2.46, 95% CI:1.37-4.41, p-value 0.003). There was no significant change in stillbirth or referral rates. CONCLUSIONS: Our findings showed positive impacts of the upskilling program on CHW knowledge and practice of participants, facility births rates, and appropriateness of referrals, demonstrating its promise as a feasible intervention to improve uptake of maternal and newborn care services in rural and remote, low-resource settings within the resourcing available to local authorities. Larger-scale evaluations of a size adequately powered to ascertain impact of the intervention on stillbirth rates are warranted.

Evolving narratives on signal functions for monitoring maternal and newborn health services: A meta-narrative inspired review.

Emergency obstetric care (EmOC) signal functions are a shortlist of key clinical interventions capable of averting deaths from the five main direct causes of maternal mortality; they have been used since 1997 as a part of an EmOC monitoring framework to track the availability of EmOC services in low- and middle-income settings. Their widespread use and proposed adaptation to include other types of care, such as care for newborns, is testimony to their legacy as part of the measurement architecture within reproductive health. Yet, much has changed in the landscape of maternal and newborn health (MNH) since the initial introduction of EmOC signal functions. As part of a project to revise the EmOC monitoring framework, we carried out a meta-narrative inspired review to reflect on how signal functions have been developed and conceptualised over the past two decades, and how different narratives, which have emerged alongside the evolving MNH landscape, have played a role in the conceptualisation of the signal function measurement. We identified three overarching narrative traditions: 1) clinical 2) health systems and 3) human rights, that dominated the discourse and critique around the use of signal functions. Through an iterative synthesis process including 19 final articles selected for the review, we explored patterns of conciliation and areas of contradiction between the three narrative traditions. We summarised five meta-themes around the use of signal functions: i) framing the boundaries; ii) moving beyond clinical capability; iii) capturing the woods versus the trees; iv) grouping signal functions and v) measurement challenges. We intend for this review to contribute to a better understanding of the discourses around signal functions, and to provide insight for the future roles of this monitoring approach for emergency obstetric and newborn care.

Level of knowledge about neonatal danger signs and associated factors among postpartum mothers in public hospitals, northeastern Ethiopia.

BACKGROUND: Knowing and seeking medical attention for neonatal danger signs has many benefits for reducing neonatal morbidity and death. Despite numerous interventions that have been made to raise mothers' awareness about neonatal danger signs, the desired level of knowledge has not yet been reached in Ethiopia. OBJECTIVE: To assess the level of knowledge of neonatal danger signs and associated factors among postpartum mothers in public hospitals in the Eastern Amhara region, northeastern Ethiopia. METHODS: A hospital-based cross-sectional study was conducted in four government hospitals between January 10, 2023, and February 10, 2023.421 participants in the study were selected using a systematic random sampling technique. Face-to-face interviews, observation, and chart reviews were used to collect the data. The association was discovered through multivariate logistic regression analysis. RESULT: Only 36.6% (154) of mothers were knowledgeable about newborn danger signs in this study. Mothers who had higher institution status [(adjusted odds ratio) AOR = 3.355, 95% CI (1.751, 6.428)]; who were civil servants or a private employer [AOR = 2.986, 95% CI (1.822, 4.892)] and [AOR = 2.544, 95% CI (1.269, 5.138)]; and who had counseling about breastfeeding [AOR = 2.614, 95% CI (1.695, 4.029)] were positive predictors of awareness of neonatal danger signs. CONCLUSION: In this study, the level of mothers' awareness of newborn danger signs was low and required more effort. Moreover, mothers who were educated, worked as civil servants or private employers, had a family size of 4-6, and received breastfeeding counseling were linked to mothers' good awareness of newborn danger signs. As a result, intensive community and facility-based health promotion activities on newborn danger signs should be strengthened, with special emphasis on uneducated and housewife mothers and breastfeeding counseling sessions.

Global health systems strengthening: FIGO's strategic view on reducing maternal and newborn mortality worldwide.

OBJECTIVE: To demonstrate that successful health systems strengthening (HSS) projects have addressed disparities and inequities in maternal and perinatal care in low-income countries. METHODS: A comprehensive literature review covered the period between 1980 and 2022, focusing on successful HSS interventions within health systems' seven core components that improved maternal and perinatal care. RESULTS: The findings highlight the importance of integrating quality interventions into robust health systems, as this has been shown to reduce maternal and newborn mortality. However, several challenges, including service delivery gaps, poor data use, and funding deficits, continue to hinder the delivery of quality care. To improve maternal and newborn health outcomes, a comprehensive HSS strategy is essential, which should include infrastructure enhancement, workforce skill development, access to essential medicines, and active community engagement. CONCLUSION: Effective health systems, leadership, and community engagement are crucial for a comprehensive HSS approach to catalyze progress toward universal health coverage and global improvements in maternal and newborn health.

Appraising LaQshya's potential in measuring quality of care for mothers and newborns: a comprehensive review of India's Labor Room Quality Improvement Initiative.

BACKGROUND: Poor intrapartum care in India contributes to high maternal and newborn mortality. India's Labor Room Quality Improvement Initiative (LaQshya) launched in 2017, aims to improve intrapartum care by minimizing complications, enforcing protocols, and promoting respectful maternity care (RMC). However, limited studies pose a challenge to fully examine its potential to assess quality of maternal and newborn care. This study aims to bridge this knowledge gap and reviews LaQshya's ability to assess maternal and newborn care quality. Findings will guide modifications for enhancing LaQshya's effectiveness. METHODS: We reviewed LaQshya's ability to assess the quality of care through a two-step approach: a comprehensive descriptive analysis using document reviews to highlight program attributes, enablers, and challenges affecting LaQshya's quality assessment capability, and a comparison of its measurement parameters with the 352 quality measures outlined in the WHO Standards for Maternal and Newborn Care. Comparing LaQshya with WHO standards offers insights into how its measurement criteria align with global standards for assessing maternity and newborn care quality. RESULTS: LaQshya utilizes several proven catalysts to enhance and measure quality- institutional structures, empirical measures, external validation, certification, and performance incentives for high-quality care. The program also embodies contemporary methods like quality circles, rapid improvement cycles, ongoing facility training, and plan-do-check, and act (PDCA) strategies for sustained quality enhancement. Key drivers of LaQshya's assessment are- leadership, staff mentoring, digital infrastructure and stakeholder engagement from certified facilities. However, governance issues, understaffing, unclear directives, competency gaps, staff reluctance towards new quality improvement approaches inhibit the program, and its capacity to enhance quality of care. LaQshya addresses 76% of WHO's 352 quality measures for maternal and newborn care but lacks comprehensive assessment of crucial elements: harmful labor practices, mistreatment of mothers or newborns, childbirth support, and effective clinical leadership and supervision. CONCLUSION: LaQshya is a powerful model for evaluating quality of care, surpassing other global assessment tools. To achieve its maximum potential, we suggest strengthening district governance structures and offering tailored training programs for RMC and other new quality processes. Furthermore, expanding its quality measurement metrics to effectively assess provider accountability, patient outcomes, rights, staff supervision, and health facility leadership will increase its ability to assess quality improvements.

Quantifying health facility service readiness for small and sick newborn care: comparing standards-based and WHO level-2 + scoring for 64 hospitals implementing with NEST360 in Kenya, Malawi, Nigeria, and Tanzania.

BACKGROUND: Service readiness tools are important for assessing hospital capacity to provide quality small and sick newborn care (SSNC). Lack of summary scoring approaches for SSNC service readiness means we are unable to track national targets such as the Every Newborn Action Plan targets. METHODS: A health facility assessment (HFA) tool was co-designed by Newborn Essential Solutions and Technologies (NEST360) and UNICEF with four African governments. Data were collected in 68 NEST360-implementing neonatal units in Kenya, Malawi, Nigeria, and Tanzania (September 2019-March 2021). Two summary scoring approaches were developed: a) standards-based, including items for SSNC service readiness by health system building block (HSBB), and scored on availability and functionality, and b) level-2 + , scoring items on readiness to provide WHO level-2 + clinical interventions. For each scoring approach, scores were aggregated and summarised as a percentage and equally weighted to obtain an overall score by hospital, HSBB, and clinical intervention. RESULTS: Of 1508 HFA items, 1043 (69%) were included in standards-based and 309 (20%) in level-2 + scoring. Sixty-eight neonatal units across four countries had median standards-based scores of 51% [IQR 48-57%] at baseline, with variation by country: 62% [IQR 59-66%] in Kenya, 49% [IQR 46-51%] in Malawi, 50% [IQR 42-58%] in Nigeria, and 55% [IQR 53-62%] in Tanzania. The lowest scoring was family-centred care [27%, IQR 18-40%] with governance highest scoring [76%, IQR 71-82%]. For level-2 + scores, the overall median score was 41% [IQR 35-51%] with variation by country: 50% [IQR 44-53%] in Kenya, 41% [IQR 35-50%] in Malawi, 33% [IQR 27-37%] in Nigeria, and 41% [IQR 32-52%] in Tanzania. Readiness to provide antibiotics by culture report was the highest-scoring intervention [58%, IQR 50-75%] and neonatal encephalopathy management was the lowest-scoring [21%, IQR 8-42%]. In both methods, overall scores were low (< 50%) for 27 neonatal units in standards-based scoring and 48 neonatal units in level-2 + scoring. No neonatal unit achieved high scores of > 75%. DISCUSSION: Two scoring approaches reveal gaps in SSNC readiness with no neonatal units achieving high scores (> 75%). Government-led quality improvement teams can use these summary scores to identify areas for health systems change. Future analyses could determine which items are most directly linked with quality SSNC and newborn outcomes.

Health facility assessment of small and sick newborn care in low- and middle-income countries: systematic tool development and operationalisation with NEST360 and UNICEF.

BACKGROUND: Each year an estimated 2.3 million newborns die in the first 28 days of life. Most of these deaths are preventable, and high-quality neonatal care is fundamental for surviving and thriving. Service readiness is used to assess the capacity of hospitals to provide care, but current health facility assessment (HFA) tools do not fully evaluate inpatient small and sick newborn care (SSNC). METHODS: Health systems ingredients for SSNC were identified from international guidelines, notably World Health Organization (WHO), and other standards for SSNC. Existing global and national service readiness tools were identified and mapped against this ingredients list. A novel HFA tool was co-designed according to a priori considerations determined by policymakers from four African governments, including that the HFA be completed in one day and assess readiness across the health system. The tool was reviewed by > 150 global experts, and refined and operationalised in 64 hospitals in Kenya, Malawi, Nigeria, and Tanzania between September 2019 and March 2021. RESULTS: Eight hundred and sixty-six key health systems ingredients for service readiness for inpatient SSNC were identified and mapped against four global and eight national tools measuring SSNC service readiness. Tools revealed major content gaps particularly for devices and consumables, care guidelines, and facility infrastructure, with a mean of 13.2% (n = 866, range 2.2-34.4%) of ingredients included. Two tools covered 32.7% and 34.4% (n = 866) of ingredients and were used as inputs for the new HFA tool, which included ten modules organised by adapted WHO health system building blocks, including: infrastructure, pharmacy and laboratory, medical devices and supplies, biomedical technician workshop, human resources, information systems, leadership and governance, family-centred care, and infection prevention and control. This HFA tool can be conducted at a hospital by seven assessors in one day and has been used in 64 hospitals in Kenya, Malawi, Nigeria, and Tanzania. CONCLUSION: This HFA tool is available open-access to adapt for use to comprehensively measure service readiness for level-2 SSNC, including respiratory support. The resulting facility-level data enable comparable tracking for Every Newborn Action Plan coverage target four within and between countries, identifying facility and national-level health systems gaps for action.

Using unsafe traditional practices by Iraqi mothers to treat newborns' problems.

Background: Unsafe traditional practices are performed in different societies, especially in developing countries, owing to poverty and low levels of education. Traditional practices are usually derived from the relationship between the environment and human attitudes toward nature. Some traditional practices originate from religious beliefs, cultures, or relatives advising new mothers. Objectives: To identify the types of unsafe traditional practices, understand the factors influencing their prevalence, and explore the potential consequences of these practices on newborn health. Methods: This descriptive, correlational study included 200 newborns whose mothers visited primary healthcare centers in Baghdad City. This study was conducted between January 2023 and June 2023. Data were collected from mothers by answering a questionnaire during interviews. The questionnaire consisted of two main parts: sociodemographic characteristics of the mothers and their newborns and 26 questions about traditional practices used to treat health problems in newborns. Results: A high percentage (84%) of Iraqi mothers used unsafe traditional practices to treat their newborns' problems (jaundice, gastrointestinal problems, sleep problems, eye problems, respiratory problems, bathing, and daily care). Conclusion: Many Iraqi mothers prefer to use traditional practices such as herbs, oils, burning, and Sagwa to treat their newborns' health problems. These practices can be harmful to newborns and threaten their lives. Therefore, it is recommended that mothers' awareness of traditional practices be increased.

How do postnatal care guidelines in Australia compare to international standards? A scoping review and comparative analysis.

BACKGROUND: There is no single national guideline in Australia on the provision of postnatal care, which means there is potential for significant variation in the standard and quality of care. This review aimed to systematically identify, synthesise, and assess the quality of postnatal care guidelines produced for use in Australia. A second aim was to compare postnatal care recommendations in Australian guidelines to the National Institute for Health and Care Excellence's (NICE) and the World Health Organization's (WHO) postnatal care recommendations, to identify gaps and areas of disagreement. We focussed on recommendations regarding postnatal assessment of the woman or newborn, infant feeding, discharge planning, or community-based care. METHODS: A scoping review was undertaken informed by the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews. A database search and a manual search of state and national government health departments, professional associations and research institute websites was performed to identify relevant guidelines and recommendations. Guideline quality was assessed using the AGREE II tool. Guideline recommendations from Australia were mapped to 67 NICE/WHO recommendations. Recommendations that partially agreed, were modified, or in disagreement underwent further analysis. RESULTS: A total of 31 Australian postnatal guidelines were identified and overall, these were of moderate- to high-quality. Of the 67 NICE/WHO recommendations, most agreed with the recommendations contained in Australian guidelines. There were five NICE/WHO recommendations with which corresponding Australian recommendations disagreed. There were 12 NICE/WHO recommendations that were commonly modified within Australia's guidelines. There were three NICE/WHO recommendations that did not appear in any Australian guideline. CONCLUSIONS: Recommendations from postnatal guidelines in Australia have a high level of agreement with corresponding NICE/WHO recommendations. The few disagreements and modifications found in guideline recommendations - both across Australia's guidelines and between Australia's and the NICE/WHO guidelines - are worrying and warrant further examination, as they may result in different standards of care across Australia. Identified gaps in guidance should be prioritised for inclusion in new or updated guidelines where appropriate.

Rosie, a Health Education Question-and-Answer Chatbot for New Mothers: Randomized Pilot Study.

BACKGROUND: Stark disparities exist in maternal and child outcomes and there is a need to provide timely and accurate health information. OBJECTIVE: In this pilot study, we assessed the feasibility and acceptability of a health chatbot for new mothers of color. METHODS: Rosie, a question-and-answer chatbot, was developed as a mobile app and is available to answer questions about pregnancy, parenting, and child development. From January 9, 2023, to February 9, 2023, participants were recruited using social media posts and through engagement with community organizations. Inclusion criteria included being aged ≥14 years, being a woman of color, and either being currently pregnant or having given birth within the past 6 months. Participants were randomly assigned to the Rosie treatment group (15/29, 52% received the Rosie app) or control group (14/29, 48% received a children's book each month) for 3 months. Those assigned to the treatment group could ask Rosie questions and receive an immediate response generated from Rosie's knowledgebase. Upon detection of a possible health emergency, Rosie sends emergency resources and relevant hotline information. In addition, a study staff member, who is a clinical social worker, reaches out to the participant within 24 hours to follow up. Preintervention and postintervention tests were completed to qualitatively and quantitatively evaluate Rosie and describe changes across key health outcomes, including postpartum depression and the frequency of emergency room visits. These measurements were used to inform the clinical trial's sample size calculations. RESULTS: Of 41 individuals who were screened and eligible, 31 (76%) enrolled and 29 (71%) were retained in the study. More than 87% (13/15) of Rosie treatment group members reported using Rosie daily (5/15, 33%) or weekly (8/15, 53%) across the 3-month study period. Most users reported that Rosie was easy to use (14/15, 93%) and provided responses quickly (13/15, 87%). The remaining issues identified included crashing of the app (8/15, 53%), and users were not satisfied with some of Rosie's answers (12/15, 80%). Mothers in both the Rosie treatment group and control group experienced a decline in depression scores from pretest to posttest periods, but the decline was statistically significant only among treatment group mothers (P=.008). In addition, a low proportion of treatment group infants had emergency room visits (1/11, 9%) compared with control group members (3/13, 23%). Nonetheless, no between-group differences reached statistical significance at P<.05. CONCLUSIONS: Rosie was found to be an acceptable, feasible, and appropriate intervention for ethnic and racial minority pregnant women and mothers of infants owing to the chatbot's ability to provide a personalized, flexible tool to increase the timeliness and accessibility of high-quality health information to individuals during a period of elevated health risks for the mother and child. TRIAL REGISTRATION: ClinicalTrials.gov NCT06053515; https://clinicaltrials.gov/study/NCT06053515.

Adherence to Practice Guidelines in the Implementation of Emergency Obstetric and Newborn Care in Referral Hospitals in Osun State, Nigeria.

Introduction: While practice guidelines support clinical decision-making for optimal patient outcomes, there is often nonadherence to practice guidelines in implementing evidence-based interventions. Objectives: This article aimed to assess adherence to practice guidelines in emergency obstetric and newborn care (EmONC) and the outcome of pregnancy in cases of obstetric complications in referral hospitals. Method: The study employed a descriptive design. A purposive sampling technique was used to select the three tertiary hospitals and six out of nine state hospitals in Osun State. A data extraction form developed based on a fidelity framework was used to collect data on Adherence from 264 cases of obstetric complications. Descriptive statistics, such as frequency and percentage, and inferential statistics, such as chi-square, were done with the significance level set as p < .05. Results: Findings showed low adherence to practice guidelines in 70.8% of hemorrhage care, 52.0% of fetal distress care, 60.0% of prolonged obstructed labor care, and 44.4% of preeclampsia/eclampsia care. The study's findings also showed that 64.3% of cases of prolonged/obstructed labor, 54.9% of cases of fetal distress, and 46.7% of all cases of obstetric complications were referred out at the state hospitals. Neonatal mortality in state and tertiary hospitals was 3.7% and 21.7%, respectively, which was significantly different (p < .001). Conclusion: There was low adherence to practice guidelines for the implementation of EmONC in state and tertiary hospitals, and a significant number of cases of obstetric complications were referred out in the state hospitals. The low adherence to practice guidelines and numerous referrals truncate the successful implementation of EmONC and hinder women and newborns from receiving optimal care for obstetric complications. There is a need to develop strategies that promote adherence to practice guidelines in implementing EmONC.

Parental readiness for hospital discharge and the relationship with growth and development of infant in China.

PURPOSE: This study aimed to evaluate the associations between parental readiness for discharge and neonatal growth. DESIGN AND METHODS: This cross-sectional study included 549 newborns whose parents filled out the Newborn-Parental Readiness for Discharge Scale (N-PRDS).Additionally, data on birth weight, length, and head circumference were collected.The total N-PRDS scores were divided into three levels in terms of readiness: low, intermediate, and high readiness. Parents and infants were followed up 42 days after the birth, and the weight, length, and head circumference of the newborns were measured at the hospital. RESULTS: A total of 306 data were obtained. The generalized linear mixed model (GLMM) showed that time and parental readiness had an interaction effect on the weight, length and head circumference of infants. The difference in weight between infants under the high and low readiness conditions at 42 days increased by 0.357 kg compared to the difference at birth. The difference in length between high readiness infants and low readiness infants at 42 days increased by 2.155 cm compared to the difference at birth. The difference between the infants' head circumference under the high and low readiness conditions at 42 days was 0.873 cm higher than that at birth. CONCLUSIONS: High readiness for discharge could promote an increase in infant weight, length,and head circumference at 42 days after birth. PRACTICE IMPLICATIONS: Nurses should assess parental readiness prior to the discharge of newborns by using the N-PRDS and provide discharge guidance and education to newborns' parents based on the outcomes of this scale.

Physician personal breastfeeding experience and clinical care of the breastfeeding dyad.

BACKGROUND: Prior research suggests that physicians' personal experience with breastfeeding may influence their attitudes toward breastfeeding. This phenomenon has not been explored in well-newborn care physician leaders, whose administrative responsibilities often include drafting and approval of hospital breastfeeding and formula supplementation policies. METHODS: We conducted a mixed-methods study, surveying physicians in the Better Outcomes through Research for Newborns (BORN) network. We examined physician attitudes toward recommending breastfeeding and their breastfeeding experience. Qualitative analysis was conducted on responses to the question: "How do you think your breastfeeding experience influences your clinical practice?" RESULTS: Of 71 participants, most (92%) had a very positive attitude toward breastfeeding with 75% of respondents reporting personal experience with breastfeeding. Of these, 68% had a very positive experience, 25% had a somewhat positive experience, and 6% had a neutral experience. Four themes emerged with respect to the effect of breastfeeding experience on practice: (1) empathy with breastfeeding struggles, (2) increased knowledge and skills, (3) passion for breastfeeding benefits, and (4) application of personal experience in lieu of evidence-based medicine, particularly among those who struggled with breastfeeding. CONCLUSIONS: Well-newborn care physician leaders reported positive attitudes about breastfeeding, increased support toward breastfeeding persons, and a perception of improved clinical lactation skills. Those who struggled with breastfeeding reported increased comfort with recommending formula supplementation to their own patients. Medical education about evidence-based breastfeeding support practices and provision of lactation support to physicians has the potential to affect public health through improved care for the patients they serve.

Opinion and Beliefs of Physicians about Integrating Families into the Care System of Preterm Hospitalized Neonates- A Qualitative Experience.

OBJECTIVES: To explore the opinions and beliefs of physicians about integrating families into the care system of hospitalized preterm neonates. METHODS: The setting was Neonatal Intensive Care Unit (NICU) of a tertiary care center in North India. Focus group discussions (FGDs) were conducted with the physicians using a pre-validated FGD topic guide. The FGDs were audio-recorded and transcribed. The meanings were drawn, and dependability was ensured. Themes and sub-themes were generated and finalized with a common consensus. RESULTS: Five FGDs were conducted involving 28 physicians. The physicians opined that making families a part of the care system has several benefits, though they brought out some concerns. They opined that involving parents gives them confidence and satisfaction as they get empowered about neonatal care at the hospital and home after discharge. They reported difficulties in communication due to perceived inadequacy in counseling skills, language barriers and literacy levels of families, and lack of adequate time due to clinical overload. They identified nurses and public health nurses as an important bridge between physicians and families, and peer support as a useful facilitator. They suggested that role assignments to team members, training in counseling and communication, improving the comfort of parents and organizing information in easy-to-understand audio- visual content can help improve the family integration. CONCLUSIONS: The physicians highlighted practical barriers, facilitators, and remedial measures to effectively integrate the families into the care system of preterm hospitalized neonates. There is a need to address the concerns of all stakeholders including the physicians for successful implementation of family integration.

Effect of the Mamás del Río programme on essential newborn care: a three-year before-and-after outcome evaluation of a community-based, maternal and neonatal health intervention in the Peruvian Amazon.

Background: Despite remarkable progress in maternal and neonatal health, regional inequalities persist in Peru. In rural areas of Amazonian Loreto, access to quality care is difficult, home births are frequent, and neonatal mortality is high. We conducted a prospective before-and-after study to assess the effect after implementation and over time of a community-based intervention on essential newborn care (ENC). Methods: Mamás del Río consists of tablet-enhanced educational home visits by Community health workers (CHW) to pregnant women and mothers of newborns, with supportive training on ENC of traditional birth attendants and facility staff. The study area comprised 79 rural communities of three districts in Loreto. Primary outcomes were ENC practices in home births, secondary outcomes were ENC in facility births as well as healthcare seeking, measured at baseline before and at year 2 and year 3 after intervention implementation. Community censuses included questionnaires to women aged 15-49 years with a live birth. We calculated prevalence of outcomes at each time point and estimated adjusted prevalence differences (PD) between time points using post-estimation based on logistic regression. Findings: Following implementation early 2019, 97% of communities had a trained CHW. At year 2 follow-up, 63% (322/530) of women received a CHW visit during pregnancy. Seven out of nine ENC indicators among home births improved, with largest adjusted prevalence differences in immediate skin-to-skin contact (50% [95% CI: 42-58], p < 0.0001), colostrum feeding (45% [35-54], p < 0.0001), and cord care (19% [10-28], p = 0.0001). Improvements were maintained at year 3, except for cord care. At year 2, among facility births only three ENC indicators improved, while more women gave birth in a facility. Sensitivity analyses showed ENC prevalence was similar before compared to after onset of Covid-19 lockdown. Interpretation: ENC practices in home births improved consistently and changes were sustained over time, despite the onset of the Covid-19 pandemic. A community-based approach for behaviour-change in home-based newborn care appears effective. Process evaluation of mechanisms will help to explain observed effects and understand transferability of findings. Funding: Grand Challenges Canada and Peruvian National Council of Science and Technology.

An assessment of immediate newborn care readiness and availability in Nepal.

BACKGROUND: Global neonatal mortality necessitates access to immediate newborn care interventions. In Nepal, disparities persist in the readiness and availability of newborn care services within health facilities. OBJECTIVE: This study aimed to assess this status and compare facilities that had implemented an intensive newborn resuscitation capacity building and retention programme in the past five years with those that had not. METHODS: Our observational cross-sectional study involved 154 health facilities across Nepal. Through on-site inspections and maternal log reviews, we evaluated the immediate newborn care readiness and availability. RESULTS: The mean immediate newborn care intervention availability score of 52.8% (SE = 21.5) and the readiness score averaged 79.6% (SE = 12.3). Encouragingly, 96% of facilities ensured newborns were dried and wrapped for warmth, and 69.9% provided newborn resuscitation. Practices such as delayed cord clamping (42.0%), skin-to-skin contact (28.6%), and early breastfeeding (63.5%) showed room for improvement. Only 16.1% of health facilities administered Vitamin K1 prophylaxis.Domain-specific scores demonstrated a high level of facility readiness in infrastructure (97.5%), medicine, equipment, and supplies (90.6%), and staff training (90.9%), but a lower score for neonatal resuscitation aids (28.8%). Disparities in readiness and availability were evident, with rural areas and the Madhesh province reporting lower scores. Variations among health facility types revealed provincial and private hospitals outperforming local-level facilities. A positive association was observed between the LDSC/SSN mentoring programme and both the readiness and availability of immediate newborn care services. CONCLUSION: This study highlights the gap between healthcare facility readiness and the actual availability of immediate newborn care interventions in Nepal. Addressing disparities and barriers, particularly in rural areas and local-level facilities, is crucial for improving neonatal survival. The positive link between the LDSC/SSN programme and service availability and facility readiness emphasises the significance of targeted training and mentorship programmes in enhancing newborn care across Nepal.

Protecting small and sick newborn care in the COVID-19 pandemic: multi-stakeholder qualitative data from four African countries with NEST360.

BACKGROUND: Health system shocks are increasing. The COVID-19 pandemic resulted in global disruptions to health systems, including maternal and newborn healthcare seeking and provision. Yet evidence on mitigation strategies to protect newborn service delivery is limited. We sought to understand what mitigation strategies were employed to protect small and sick newborn care (SSNC) across 65 facilities Kenya, Malawi, Nigeria and Tanzania, implementing with the NEST360 Alliance, and if any could be maintained post-pandemic. METHODS: We used qualitative methods (in-depth interviews n=132, focus group discussions n=15) with purposively sampled neonatal health systems actors in Kenya, Malawi, Nigeria and Tanzania. Data were collected from September 2021 - August 2022. Topic guides were co-developed with key stakeholders and used to gain a detailed understanding of approaches to protect SSNC during the COVID-19 pandemic. Questions explored policy development, collaboration and investments, organisation of care, human resources, and technology and device innovations. Interviews were conducted by experienced qualitative researchers and data were collected until saturation was reached. Interviews were digitally recorded and transcribed verbatim. A common coding framework was developed, and data were coded via NVivo and analysed using a thematic framework approach. FINDINGS: We identified two pathways via which SSNC was strengthened. The first pathway, COVID-19 specific responses with secondary benefit to SSNC included: rapid policy development and adaptation, new and collaborative funding partnerships, improved oxygen systems, strengthened infection prevention and control practices. The second pathway, health system mitigation strategies during the pandemic, included: enhanced information systems, human resource adaptations, service delivery innovations, e.g., telemedicine, community engagement and more emphasis on planned preventive maintenance of devices. Chronic system weaknesses were also identified that limited the sustainability and institutionalisation of actions to protect SSNC. CONCLUSION: Innovations to protect SSNC in response to the COVID-19 pandemic should be maintained to support resilience and high-quality routine SSNC delivery. In particular, allocation of resources to sustain high quality and resilient care practices and address remaining gaps for SSNC is critical.

Neonatal inpatient dataset for small and sick newborn care in low- and middle-income countries: systematic development and multi-country operationalisation with NEST360.

BACKGROUND: Every Newborn Action Plan (ENAP) coverage target 4 necessitates national scale-up of Level-2 Small and Sick Newborn Care (SSNC) (with Continuous Positive Airway Pressure (CPAP)) in 80% of districts by 2025. Routine neonatal inpatient data is important for improving quality of care, targeting equity gaps, and enabling data-driven decision-making at individual, district, and national-levels. Existing neonatal inpatient datasets vary in purpose, size, definitions, and collection processes. We describe the co-design and operationalisation of a core inpatient dataset for use to track outcomes and improve quality of care for small and sick newborns in high-mortality settings. METHODS: A three-step systematic framework was used to review, co-design, and operationalise this novel neonatal inpatient dataset in four countries (Malawi, Kenya, Tanzania, and Nigeria) implementing with the Newborn Essential Solutions and Technologies (NEST360) Alliance. Existing global and national datasets were identified, and variables were mapped according to categories. A priori considerations for variable inclusion were determined by clinicians and policymakers from the four African governments by facilitated group discussions. These included prioritising clinical care and newborn outcomes data, a parsimonious variable list, and electronic data entry. The tool was designed and refined by > 40 implementers and policymakers during a multi-stakeholder workshop and online interactions. RESULTS: Identified national and international datasets (n = 6) contained a median of 89 (IQR:61-154) variables, with many relating to research-specific initiatives. Maternal antenatal/intrapartum history was the largest variable category (21, 23.3%). The Neonatal Inpatient Dataset (NID) includes 60 core variables organised in six categories: (1) birth details/maternal history; (2) admission details/identifiers; (3) clinical complications/observations; (4) interventions/investigations; (5) discharge outcomes; and (6) diagnosis/cause-of-death. Categories were informed through the mapping process. The NID has been implemented at 69 neonatal units in four African countries and links to a facility-level quality improvement (QI) dashboard used in real-time by facility staff. CONCLUSION: The NEST360 NID is a novel, parsimonious tool for use in routine information systems to inform inpatient SSNC quality. Available on the NEST360/United Nations Children's Fund (UNICEF) Implementation Toolkit for SSNC, this adaptable tool enables facility and country-level comparisons to accelerate progress toward ENAP targets. Additional linked modules could include neonatal at-risk follow-up, retinopathy of prematurity, and Level-3 intensive care.

Blood culture versus antibiotic use for neonatal inpatients in 61 hospitals implementing with the NEST360 Alliance in Kenya, Malawi, Nigeria, and Tanzania: a cross-sectional study.

BACKGROUND: Thirty million small and sick newborns worldwide require inpatient care each year. Many receive antibiotics for clinically diagnosed infections without blood cultures, the current 'gold standard' for neonatal infection detection. Low neonatal blood culture use hampers appropriate antibiotic use, fuelling antimicrobial resistance (AMR) which threatens newborn survival. This study analysed the gap between blood culture use and antibiotic prescribing in hospitals implementing with Newborn Essential Solutions and Technologies (NEST360) in Kenya, Malawi, Nigeria, and Tanzania. METHODS: Inpatient data from every newborn admission record (July 2019-August 2022) were included to describe hospital-level blood culture use and antibiotic prescription. Health Facility Assessment data informed performance categorisation of hospitals into four tiers: (Tier 1) no laboratory, (Tier 2) laboratory but no microbiology, (Tier 3) neonatal blood culture use < 50% of newborns receiving antibiotics, and (Tier 4) neonatal blood culture use > 50%. RESULTS: A total of 144,146 newborn records from 61 hospitals were analysed. Mean hospital antibiotic prescription was 70% (range = 25-100%), with 6% mean blood culture use (range = 0-56%). Of the 10,575 blood cultures performed, only 24% (95%CI 23-25) had results, with 10% (10-11) positivity. Overall, 40% (24/61) of hospitals performed no blood cultures for newborns. No hospitals were categorised as Tier 1 because all had laboratories. Of Tier 2 hospitals, 87% (20/23) were District hospitals. Most hospitals could do blood cultures (38/61), yet the majority were categorised as Tier 3 (36/61). Only two hospitals performed > 50% blood cultures for newborns on antibiotics (Tier 4). CONCLUSIONS: The two Tier 4 hospitals, with higher use of blood cultures for newborns, underline potential for higher blood culture coverage in other similar hospitals. Understanding why these hospitals are positive outliers requires more research into local barriers and enablers to performing blood cultures. Tier 3 facilities are missing opportunities for infection detection, and quality improvement strategies in neonatal units could increase coverage rapidly. Tier 2 facilities could close coverage gaps, but further laboratory strengthening is required. Closing this culture gap is doable and a priority for advancing locally-driven antibiotic stewardship programmes, preventing AMR, and reducing infection-related newborn deaths.