This study assessed the knowledge gaps of IHCPs in Ujjain district, MP, India, on evidence-based practices of neonatal care. Of the potential 39,840 points, only 18,483 (46%) were achieved, indicating a gap in knowledge. IHCPs presented good knowledge of the initiation and frequency of breastfeeding and identified the best practices in protecting low-birth-weight babies from hypothermia. However, the practitioners lacked knowledge about the duration of exclusive breastfeeding, neonatal resuscitation, the correct dosage for vitamin K in neonatal hemorrhage prophylaxis, umbilical cord care, and follow-up on the immunization status of the children. A know-do gap existed in understanding the importance of measuring weights of the children and practically measuring weights. Fair knowledge of practitioners was significantly associated with attending more than 10 but less than 50 patients per day and of being aged between 35 and 45 years.
Most of the published studies on IHCPs have focused on characterizing the scope of their work, utilization patterns, and reason for their popularity, especially in low-income countries [9]. It is perceived that IHCPs provide substandard care compared with formally trained health care providers. However, not many studies have characterized the knowledge gap among IHCPs. A study conducted in Bangladesh revealed that IHCPs scored lower than allopathic (trained) paramedical professionals on the knowledge of adequate drug provisions [17]. A study conducted in Vietnam revealed irrational dispensing of antibiotics, noncompliance to national guidelines, and increased use of traditional medicines [17]. However, extremely few studies have been conducted on the knowledge gap of IHCPs on evidence-based practice in neonatal care [9]. In a field trial conducted in rural Gadchiroli, India [18], home-based interventions for birth-asphyxia delivered by a team of traditional birth attendants and semiskilled village health workers reduced the asphyxia-related NM by 65% compared with that by only the traditional birth attendants [18]. Since, birth-asphyxia is one of the major cause of neonatal mortality and morbidity and since most of the IHCPs in our study did not do well in identifying the initial steps of resuscitation an intervention similar to the Gadchiroli home-based intervention [18] could yield high dividends in reducing NM.
The duration of breastfeeding was unknown to most IHCPs in the present study; however, it is not well-known even to qualified health care workers [15]. Inadequate knowledge on the use of vitamin K for prophylaxis against neonatal bleeding and the use of bag and mask for resuscitation in the present study was similar to that reported in a study from Vietnam [15]. This could be due to lack of knowledge and skills among IHCPs of basic resuscitation equipment and drugs [15]. However, an obvious know-do gap existed among IHCPs who responded that they do not weigh the neonates despite being aware that dosages of drugs should be based on the weights of the children.
The absence of knowledge of safe umbilical cord care is not unique to our setting. A firm tradition of umbilical cord care has been established in every culture [19]. Cord care practices vary across countries or cultural groups within a country and include a wide range of substances [19]. Since 1998, the WHO advocates using dry umbilical cord care; however, in situations where hygienic conditions are poor and/or infection rates are high, chlorhexidine application is recommended [20]. A total of 51% respondents in our study assumed that antibiotics should be applied to the umbilical cord. Promoting healing and hastening cord separation are the underlying beliefs related to the application of substances to the umbilical cord [19]. Among the IHCPs in our study, antibiotic application could be due to the fear of infection; it also reflects a behavior to use antibiotics irrationally. IHCP’s prescribing behavior, with high rates of antibiotic prescribing has been documented in a recent study in the same area [21].
The response on follow-up on immunization history raises issues regarding provider awareness of the importance of this public health intervention. In 2017, an estimated 19.9 million infants worldwide were deprived of routine immunization services, such as three doses of the diphtheria, tetanus, and pertussis vaccine [22]. India accounts for one-fourth of these under-immunized children [23]. Because IHCPs become the main providers of care where the formal system has failed, the risk factors for incomplete immunization, such as illiteracy among mothers, living in rural areas, belonging to scheduled tribes/castes, and high birth order, all reflecting inequity in immunization coverage [24], are also prevalent among their clients. Because the Government of India has introduced new vaccines in the recent times, IHCPs should be provided with an opportunity to become aware of the immunization services offered by the government, so that they can offer referrals to clients who need an immunization service.
The Government of India has recently launched its flagship program ‘skill development’ and has also decided to upgrade the skills of IHCPs by providing short-term training or courses [25]. We are hopeful that if appropriate skills are imparted this may help reduce the NM in India. This is important in the light of the fact that provision of formally trained health care providers in the rural health care system in India will continue to be poor in the next few years [26], the skill upgradation of IHCPs can prove to be a low hanging fruit to reduce neonatal mortality in India.
Methodological considerations
The main strength of the study is that the questionnaire used has been used before to assess the level of knowledge on evidence-based neonatal care in Vietnam among qualified primary health care workers the questionnaire used in the present study was pilot tested which strengthens internal validity. Because it was administered in Hindi, the preferred language of the respondents, forward and backward translations were performed with the help of Hindi and English language experts to ensure retained meaning of the questions post translation. A combination of single-answer and multiple-correct-answer questions has been proposed for reducing guesswork [27]; this combination was used this questionnaire.
IHCPs by definition do not possess a regulatory body. The nature of practice is also such that they might be mobile, conducting home visits but also having more than one clinic., The difficulty in developing a sampling frame was compounded by the fact that the IHCPs work in remote areas. A complex relationship of mistrust between private and public providers has been described previously in the state of MP [28], which could have hampered the ability of IHCPs to participate in the study without the fear of reprisal.