Improving newborn care practices through home visits: lessons from Malawi, Nepal, Bangladesh, and Uganda

Figures & data

Table 1 Benefits of newborn care practices promoted at community level

Practices	Specific behaviours	Benefits to newborn
Breastfeeding	Initiation of breastfeeding within 1 hour after birth	Reduced risk of death, particularly from infectious disease due to protective factors in colostrum and breast milk and protection
	Exclusive breastfeeding for 6 months	from ingestion of contaminants found in water, other fluids, and
	Continued breastfeeding with safe complementary foods after 6 months	food with exclusive breastfeeding (5) Reduced risk of morbidity, including gastro-intestinal infections and respiratory infections (6)
Cord care	Cord cut with sterile blade and cord care with sterile tie/clamp	Reduced risk of death and morbidity due to tetanus and sepsis, omphalitis, cord infection (7–10)
	Nothing harmful applied to cord (topical antibiotic/antiseptic may be recommended in some settings)
Thermal care	Immediate drying	Reduced risk of hypothermia and sequelae including (11–16)
	Delayed bathing	∘Death
	Wrapping in clean cloth and/or skin-to-skin care	∘Infection ∘Central nervous system depression leading to bradycardia, apnoea, and poor feeding ∘Coagulation defects, haemorrhage

Table 2 Community worker cadre, characteristics, training, and incentives

	Bangladesh		Malawi	Nepal	Uganda
Cadre name	• Family Welfare Assistant (FWA) • Health Assistant (HA) – Females only • Community Nutrition Promoter (CNP)		Health Surveillance Assistant (HSA)	Female Community Health Volunteer (FCHV)	Village Health Team (VHT)
Characteristics	FWA/HA:	CNP:
• Gender	• Female	• Female	• Mostly male	• Female	• Mixed
• CHW: pop. ratio	• 1:6,000–7,000	• 1:1,250	• 1:1,000–2,000	• 1:400^a	• 1:1,000
• Education level	• Secondary education	• Primary (not strict)	• Secondary	• Literate, primary preferred	• Literate
• Employment status	• Govt-salaried employee	• Volunteer (stipend)	• Govt-salaried employee	• Volunteer	• Volunteer (travel allowance)
• Recruitment	• From communities	• From communities	• Centrally recruited	• From communities	• From communities
• Pre-service training	• 21 days (FWA) 6 weeks (HA)	• 24-day training	• 12-week training	• 18-day training	• None
Training in maternal newborn community package	5 days		9 days (+6 days community mobilisation)	6 days	6 days
Paid incentives based on number of visits	No		No	Yes	No

^aCatchment area population size varies in Nepal depending on terrain; 1:400 ratio is applicable to Terai region such as Bardiya.

Table 3 Home visit schedule and messages given during home visits on newborn care practices

		Malawi	Nepal	Bangladesh	Uganda^a
		Chitipa, Dowa, Thyolo districts	Bardiya district	Faridpur district	Iganga & Mayuge districts
# Pregnancy visits		3 (1st, 2nd and 3rd trimester)	4 (4th, 6th, 8th, 9th months)	2 (2nd and 3rd trimester)	2 (early as possible and 3rd trimester)
# Postnatal visits		2–3 (day 1 – home births only, 3, 8)	4 (day 1, 3, 7, 29)	3 (day 1, 2–3, 4–7)	2 (day 1–3, 5–7)
Early initiation of breastfeeding	Messages	Initiate breastfeeding within 30 min after delivery depending on feeding option chosen by mother	Initiate breastfeeding within 1 hour after birth	Initiate breastfeeding immediately and no later than 1 hour after birth	Put baby on the breast within 1 hour of birth
	When delivered	2nd and 3rd pregnancy visit 1st postnatal visit (home births)	3rd and 4th pregnancy visit 1st postnatal visit (home births)	All pregnancy visits	1st postnatal visit
Delayed bathing	Messages	Delay bathing the baby for 24 hours after birth	Newborn should not be bathed for at least 24 hours after birth	No bath within 3 days of birth	Delay bathing until after the 1st day
	When delivered	2nd and 3rd pregnancy visit 1st postnatal visit (home births)	3rd and 4th pregnancy visit 1st postnatal visit (home births)	All pregnancy visits	1st postnatal visit
Skin-to-skin care	Messages	Place the baby on the mother's abdomen for skin-to-skin contact to promote bonding	Place the newborn close to mother and make him/her warm	Place naked baby on mother's bare chest or abdomen within 24 hours of birth Mother and infant should be covered with a clean, dry cloth	Dry the baby. Then put the naked baby between your breasts. Cover him or her lightly with a dry cloth and keep in this position as much as possible during day and night.^b
	When delivered	2nd and 3rd pregnancy visit 1st postnatal visit (home births)	3rd and 4th pregnancy visit 1st postnatal visit	All pregnancy visits	2nd postnatal visit
Cord care	Messages	Avoid applying traditional herbs or substances on the umbilical cord	Keep the cord dry and clean Do not put oil or anything onto the cord	Cord should be kept clean and dry after cutting Apply nothing to cord stump If cord is very soiled it may be cleansed gently with boiled water	Do not put anything on the cord, keep it clean and dry Let the cord stump dry and fall off on its own
	When delivered	All 3 postnatal visits	3rd and 4th pregnancy visit 1st postnatal visit (home births)	All pregnancy visits	1st postnatal visit

^aCounselling cards indicate that counselling on these behaviours should occur during the first postnatal visits. According to the study PIs, the CHWs were encouraged to deliver messages during all pregnancy and postnatal visits during training and supervision.

^bIn the VHT manual, skin-to-skin care recommended for low birthweight babies. Study PI says VHTs in study area trained to recommend skin-to-skin care for all newborns.

Table 4 Newborn care practices at baseline and endline and absolute percent change over time

		Malawi intervention			Nepal intervention			Bangladesh^a intervention			Bangladesh^a comparison			Uganda intervention			Uganda comparison
		Pre (%)	Post (%)	% change	Pre (%)	Post (%)	% change	Pre (%)	Post (%)	% change	Pre (%)	Post (%)	% change	Pre (%)	Post (%)	% change	Pre (%)	Post (%)	% change
Early initiation of breastfeeding	Yes	74	95	21*	64	90	26*	68	75	8	69	80	11*	54	86	32*	47	85	38*
	No/DK	26	5		36	10		32	25		31	20		46	14		53	15
Delayed bathing ≥6 hours	Yes	64	91	27*	78	95	17*	67	87	20*	63	73	10*	NC	90		NC	84
	No/DK	36	9		22	5		33	13		37	27			10			16
Skin-to-skin care	Yes	NC	68		NC	76		NC	80		NC	73		NC	82		NC	77
	No/DK		32			24			20			27			18			23
Nothing applied to cord	Yes	72	71	−1	NA	NA		48	79	31*	57	63	6	44	64	20*	58	52	−6
	No/DK	28	29					52	21		43	37		56	36		42	48

^aNon-facility births only. *Statistically significant change from baseline to endline at p<0.05.

NC=not collected; DK=don't know; NA=not available (questions on substances applied to the cord were only asked for non-facility births in Nepal).

Missing values <3% except: 16.7% missing early initiation of breastfeeding at baseline in Malawi, 9.2% missing delayed bathing at baseline in Malawi, 10.8% missing delayed bathing at endline in Malawi, 6.2% missing delayed bathing at baseline in Nepal. Missing values excluded from denominator to calculate absolute percentage change. Shaded portion distinguishes data from comparison areas for the 2 countries that collected data from non-intervention areas.

Table 5 Number of practices used at endline, among the three practices included in composite indicator

	Malawi (N=844)		Nepal (N=615)		Bangladesh^a (N=293)		Uganda (N=869)
No. of practices	n	%	n	%	n	%	n	%
0	6	1	8	1	3	1	9	1
1	49	6	33	5	33	11	51	6
2	367	44	155	25	93	32	252	29
3	422	50	419	68	164	56	557	64
Mean	2.43		2.60		2.43		2.56

^aNon-facility births only.

Table 6 Distribution of independent variables for women asked about the three practices included in composite indicator at endline

	Malawi (N=844)		Nepal (N=615)		Bangladesh^a (N=293)		Uganda (N=869)
	n	%	n	%	n	%	n	%
Pregnancy home visit
0	524	62	18	3	26	9	288	33
1 or 2	248	29	89	14	78	27	300	35
3+	64	8	508	83	189	65	279	32
Missing	8	1	0	0	0	0	2	<1
Antenatal care
None	32	4	212	34	169	58	36	4
At least one visit	804	95	403	66	124	42	832	96
Missing	8	1	0	0	0	0	1	<1
Place of delivery
Home	54	6	114	19			197	23
Facility	777	92	501	81			672	77
Missing	15	2	0	0			0	0
Maternal age (years)
<20	121	14	96	16	41	14	109	13
20–29	473	56	453	74	186	63	485	56
30+	230	27	66	11	66	23	275	32
Missing	20	2	0	0	0	0	0	0
Maternal education
None	103	12	258	42	54	18	97	11
Any	736	87	357	58	239	82	772	89
Missing	5	1	0	0	0	0	0	0

^aNon-facility births only.

Table 7 Generalised linear models for four countries with a composite indicator of early initiation of breastfeeding, delayed bathing, and skin-to-skin contact at endline as the dependent variable

	Malawi				Bangladesh^a				Nepal				Uganda
	n	Crude RR	Adjusted (95% CI)	p	n	Crude RR	Adjusted (95% CI)	p	n	Crude RR	Adjusted (95% CI)	p	n	Crude RR	Adjusted (95% CI)	p
Pregnancy home visits
None (Ref)	489	1.00	1.00		26	1.00	1.00		18	1.00	1.00		287	1.00	1.00
1 or 2	235	1.07	1.07 (0.91–1.27)	0.410	78	1.30	1.36 (0.77–2.39)	0.278	89	1.52	1.37 (0.89–2.12)	0.143	299	0.99	1.01 (0.90–1.14)	0.819
3+	62	1.36	1.34 (1.11–1.62)	0.003	189	1.83	1.88 (1.06–3.35)	0.032	508	1.55	1.45 (0.95–2.20)	0.082	277	1.00	1.01 (0.89–1.15)	0.840
ANC^b visit
None (Ref)	29	1.00	1.00		169				212	1.00	1.00		36	1.00	1.00
At least one	757	1.06	0.97 (0.65–1.45)	0.893	124	1.12	1.14 (0.90–1.44)	0.265	403	1.05	1.00 (0.88–1.13)	0.977	827	1.38	1.29 (0.90–1.85)	0.153
Place of delivery
Non-facility (Ref)	46	1.00	1.00		0	1.00	1.00		114	1.00	1.00		196	1.00	1.00
Facility	740	2.20	2.25 (1.28–3.93)	0.005	293	–	–	–	501	2.10	2.11 (1.56–2.84)	0.000	667	1.48	1.47 (1.30–1.66)	0.000
Maternal age
<20 (Ref)	114	1.00	1.00		41	1.00	1.00		96	1.00	1.00		109	1.00	1.00
20–29	453	1.23	1.22 (0.99–1.51)	0.056	186	1.21	1.25 (0.82–1.89)	0.287	453	1.00	1.00 (0.87–1.16)	0.962	480	1.15	1.16 (1.01–1.33)	0.041
30+	219	1.29	1.30 (1.02–1.66)	0.034	66	1.06	1.03 (0.68–1.56)	0.886	66	0.90	0.94 (0.77–1.14)	0.516	274	1.04	1.11 (0.93–1.32)	0.252
Maternal education
None (Ref)	90	1.00	1.00		54	1.00	1.00		258	1.00	1.00		95	1.00	1.00
Any	696	1.11	1.09 (0.84–1.41)	0.534	239	1.10	1.00 (0.77–1.31)	0.996	357	1.03	0.94 (0.83–1.06)	0.312	768	0.99	0.98 (0.85–1.12)	0.711
Total	786				293				615				863

^aNon-facility births only.

^bAntenatal care (at LEAST one visit with a skilled provider).

<10% missing one or more independent variable and excluded from model (approximately 7% missing values in Malawi, 1% in Uganda and 0% in Nepal and Bangladesh).

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