“You have to take action”: changing knowledge and attitudes towards newborn care practices during crisis in South Sudan

Figures & data

Table 1. Key newborn care training components for community and facility-based health workers

Training components for essential newborn care	Additional training components for managing preterm complications and severe infections	Additional training components for managing intrapartum complications
Household-level (by CHWs) • Identify pregnant women (already being done) • Demand generation for facility-based deliveries • Use of CHW-held kit and items for distribution to women • Education on application of chlorhexidine antiseptic to the umbilical cord • Home visits in the first week to promote basic newborn care (thermal care, hygiene, cord card, exclusive breastfeeding) and assess for danger signs • Assist families to refer severely ill newborns	• Assist families to refer severely ill newborns	• Immediate referral of women in labour, or preparation for safe and clean delivery at home
Facility level• Recognition of danger signs for the newborn during pregnancy • Foetal monitoring and recording during labour • Essential newborn care in immediate postnatal period:  ○ Delayed cord clamping  ○ Thermal care including immediate skin-to-skin and delay bathing >6 hours  ○ Application of chlorhexidine antiseptic to the umbilical cord  ○ Early and exclusive breastfeeding  ○ Handwashing and hygiene  ○ Clean cord and skin care  ○ Assess and counsel on danger signs  ○ Weigh the baby and record  ○ Identify and support newborns who need additional care  ○ Provide birth notification	• Complete physical exam within 2 hours • Extra thermal care through continuous KMC for stable babies <2 kg • Extra infection prevention measures and prompt treatment • Extra support for breastmilk feeding including expression as needed • Monitor and record vital signs for at least 24 hours  ○ Temperature every 4 hours  ○ Weigh daily  ○ Record feedings • Prompt identification and first dose of antibiotics, plus facilitated referral (also providing guidelines for treatment if referral is not possible) • Support to family for neonatal death or disabled survivor	• Immediate response to action line on the partograph or late decelerations in foetal heart rate, including referral if possible • Stimulation and bag and mask resuscitation of babies who are not breathing at birth • Support to family for stillbirth, neonatal death or disabled survivor

Table 2. Participant characteristics for in-depth interviews, March–October 2016

Variable	Pre-training		Post-training		Total
	No.	(%)	No.	(%)	No.	(%)
Location  Juba  Malakal  Maban	5 4 8	(29) (24) (47)	4 6 6	(25) (38) (38)	9 10 14	(27) (30) (42)
Type of health worker  Community health worker   Male   Female  Midwife   Male   Female  Traditional birth attendant   Male   Female	3 3 3 6 0 2	(18) (18) (18) (35) (0) (12)	5 1 3 3 0 4	(31) (6) (19) (19) (0) (25)	8 4 6 9 0 6	(24) (12) (18) (27) (0) (18)
Sex  Male  Female	6 11	(35) (65)	8 8	(50) (50)	14 19	(42) (58)
Mean age, years	31.5 ± 9.2		34.25 ± 10.9		32.8 ± 10.0
Education completed  Primary   Male   Female  Secondary   Male   Female  Certificate or higher   Male   Female	1 3 2 1 3 7	(6) (18) (12) (6) (18) (41)	0 3 4 2 4 3	(0) (19) (25) (13) (25) (19)	1 6 6 3 7 10	(3) (18) (18) (9) (21) (30)
Mean time employed by IMC, years   Male   Female	1.6 ± 1.6 1.7 ± 1.4		1.3 ± 0.9 2.0 ± 1.3		1.4 ± 1.2 1.8 ± 1.3

Table 3. Correct response to questionnaire to assess CHW knowledge, pre-post-training (N = 72)

Variable	Pre-training		Post-training
	No.	(%)	No.	(%)
Pregnancy, labour and birth  1. Why is it important to identify pregnant women in your community?  2. Why is it important for women to deliver their babies in a health facility?	55 42	(76.4) (58.3)	68 58	(94.4) (80.6)
Postnatal care  3. Which of the following is a sign that a baby is breastfeeding adequately?  4. When should a baby be given liquids other than breast milk?  5. What is the most important reason for weighing all babies soon after birth?  6. Why is it important to place a baby on the mother’s bare chest after delivery?  7. Why is it important to apply chlorhexidine gel to the umbilical cord of a baby?  8. What is the normal temperature range for a healthy baby?  9. How soon after birth can a healthy baby be bathed? 10. How fast should a normal baby breathe? 11. What are the key messages you should tell parents of a healthy newborn? 12. What are newborn danger signs?	35 26 46 38 34 33 21 12 25 28	(48.6) (36.1) (63.9) (52.8) (47.2) (45.8) (29.2) (16.7) (34.7) (38.9)	49 48 52 64 52 71 65 67 61 55	(68.1) (66.7) (72.2) (88.9) (72.2) (98.6) (90.3) (93.1) (84.7) (76.4)

Table 4. Correct response to questionnaire to assess facility health worker knowledge, pre-post-training (N = 25)

Variable	Pre-training		Post-training
	No.	(%)	No.	(%)
Pregnancy, labour and birth  1. How many times do you need to record the fetal heart rate on the partograph?  2. What supplies do you need to have available in the delivery room for every delivery?  3. If a baby requires resuscitation, where do you place the mask on the baby?  4. If a baby requires resuscitation, when do you clamp and cut the baby’s cord? Postnatal care  5. Why is it important to begin breastfeeding as soon as possible after birth?  6. When should a newborn be given liquids other than breast milk?  7. Babies with which problem might benefit from breastmilk feeding from a cup?  8. How often should a mother express milk for a baby who cannot feed at the breast?  9. What is the most important reason for weighing all babies soon after birth? 10. Why is it important to place a baby on the mother’s bare chest after delivery? 11. How long should initial skin-to-skin care be provided by healthy mothers of well babies? 12. How should a baby be kept warm after skin-to-skin care? 13. How soon after birth can a healthy baby be bathed? 14. How fast should a normal baby breathe? 15. What is the normal temperature range for a healthy baby? 16. At 90 minutes after birth, a 2700 gram baby has a temperature of 35.8 °C. What should you do next? 17. When should a baby be treated with antibiotics? 18. You have determined that a baby with a birthweight of 1800 grams needs antibiotics. How much ampicillin (200 mg/mL) should you give? 19. What do you apply to a baby’s cord after it is cut? 20. List five different important basic newborn care practices that mothers should receive education about. 21. List five different newborn danger signs that require immediate action.	22 24 17 16 15 14 18 20 22 21 8 22 21 20 11 17 21 16 8 6 9	(88.0) (96.0) (68.0) (64.0) (60.0) (56.0) (72.0) (80.0) (88.0) (84.0) (32.0) (88.0) (84.0) (80.0) (44.0) (68.0) (84.0) (64.0) (32.0) (24.0) (36.0)	22 25 20 11 20 17 20 17 24 24 20 23 24 23 21 20 24 19 17 13 20	(88.0) (100.0) (80.0) (44.0) (80.0) (68.0) (80.0) (68.0) (96.0) (96.0) (80.0) (92.0) (96.0) (92.0) (84.0) (80.0) (96.0) (76.0) (68.0) (52.0) (80.0)

Table 5. Summary of in-depth interviews’ emergent themes for non-adoption

Theme	Emergent sub-theme
Personal characteristics	Personal knowledge of benefit for mothers and/or newborns Personal beliefs or values placed on the importance of task
Intervention complexity	Comfort reflected by perceived difficultly or ease of task through use or knowledge Length of time taken to complete task Lack of clarity on how to implement steps required for task
Organisational facilitators	Relevant trainings or topics that need further training Organisational clinical protocols that either facilitate or hinder delivery Level of resources dedicated for tasks or ongoing operations Reference to the availability of staff for implementing tasks Level of supervision or feedback communicated to staff Network with other referral facilities including aspects of the referral process
External environment	Perceived acceptance by the community towards the task Effect of conflict on health care system