Description of Sample
A total of sixteen focus group discussions (FGDs) were conducted with grandfathers, grandmothers, mothers who have child of less than two years of age and fathers who have child of less than two years of age of community representatives. From the total discussants two groups were grandfathers, one group was grandmothers, ten groups were mothers who have child of less than two years of age and three groups were fathers who have child of less than two years of age. In these FGDs the maximum number of participants in one group was twelve and the minimum number were six. Concerning age of the participants, the maximum age was seventy three years and the minimum age seventeen. The highest level of education of the discussants was diploma and there was considerable amount of illiterate participants in the FGDs. Regarding number of children they have, the maximum number is eight and the minimum was one.
In this study, a total of forty six in-depth interviews (IDIs) were conducted among community representatives and health workers. The health worker were nurses, midwives, HEWs and the community representative were WDAs, grandfathers, grandmothers, mothers with LBW/Preterm baby who initiate KMC and who did not initiate KMC. Of the total participants, from the health workers side four were nurses, ten were midwife, five were WDA and seven were HEW. From the community representatives six were grandfathers, three were grandmothers, six were mothers with preterm baby who did not initiate KMC and nine were mothers with preterm baby who initiated KMC at health facility.
In these IDIs, the maximum age of participants was sixty and minimum age was seventeen. Regarding working experience of health workers, the maximum year of experience was fourteen and the minimum was seven months. Almost all participants from health workers group their education level was degree graduate. Concerning education level of the community representatives the highest level was tenth grade and almost half of the participants were illiterate. Regarding community representatives’ number of children they have, the maximum number was six. Half of mothers who participated in this in-depth interview had only one child.
Community perspective on newborn baby care
Health condition of a baby
The study participants repeatedly mentioned that a baby is healthy if the baby has weight gain, able to breast feed, physically active, sleeps well, able to breathe and cry but the cry shouldn’t be prolonged, the baby should be free from symptoms of illness like coughing, vomiting, fever, and diarrhea.
Focus group discussant mother who has children of less than 2 years old from semen health center, Mekelle city explained this condition “A baby is Healthy if he/she is able to sleep well for more than 12 hrs. Per day”
Another focus group discussant mother who has children of less than 2 years old from Bizet health center, Eastern Zone of the region explained “If a baby cries day & night, this might be because of health problem or the baby is sick”
Type of care needed to have a healthy baby:
According to the respondents; practice such as baby bath (hygienic care), exclusive breast feeding till 6 month then supplementary feeding, thermal care (keep warm/prevent exposure to coldness), initiate breast feeding by providing colostrum immediately after birth as much as possible, vaccination, ANC follow up, proper maternal nutrition, institutional delivery are the cares needed to have a healthy baby.
Focus group discussant mother who has children of less than 2 years old from semen health center, Mekelle city said “ Avoid providing butter as early initiation of feeding (previously it was given if the mother could not produce milk immediately) because a new born baby GI could not digest it & may create health problem”. During the in-depth interview, a grandfather from Neksege health center of southern zone said “Like a plant, newborn baby needs proper cultivation (Both plants and babies deserve strict care till they grow up properly”
Danger signs
The study participants repeatedly mentioned that the community/ family members become worried if a baby has a danger sign like vomiting & diarrhea symptoms of respiratory illness, unable to breast feed, high fever, symptoms of tonsillitis, uvulitis, measles /polio, convulsion, abdominal pain/cramp, excessive bleeding. Focus group discussant mother who has children of less than 2 years old from semen health center, Mekelle city describe this condition “I am very much worried if there is excessive bleeding from circumcision site of male baby”
Thermal care and Baby bath
Respondents repeatedly said that exposure to cold is responsible for respiratory illness which is expressed with manifestations of coughing, fast breathing, chest in-drawing, chest pain, unable to breast feed, vomiting & becoming physically weak. So early wrapping with more clothing is so important to keep warmth of the baby. Despite poor reasoning, all respondent groups recognized the importance of keeping newborns warm and well wrapped.
Focus group discussant father who has children of less than 2 years old from Guya health center, central zone. This situation described as “The father believed that if a newborn baby is exposed to coldness, he/she may develop eye discharge which might progress to Trachoma”
Focus group discussant mother who has children of less than 2 years old from Mekelle Hospital, Mekelle City stated “If a baby is exposed to coldness, he/she may develop pneumonia & this may progress to TB”
All respondents reported that newborns should be kept in a house and shouldn’t be exposed outside the room for at least the first week of life and the door & windows of the room should be closed.
Interviewed grandmother from Serawat health center of Mekelle City on current practice of baby bath responded, “This time we delay baby bath till 24 hrs of age (not immediately as previous time) to prevent coldness then attach to his/her mother to Breast feed”.
Interviewed grandmother from Alassa central zone said “I believe Newborn baby should bath immediately after birth to clear the blood”
Breast feeding
Most of the respondents were aware of the importance of early initiation of BF and the advantage of colostrum. They said mothers who gave birth at health facility were advised to initiate breast feeding immediately and not to discard colostrum.
Focus group discussant mother who had less than 2yrs children in Bizet eastern zone “For my baby I initiate with Breast milk (colostrum) it should not be other thing (like butter or sugar & water)”
The main reason given by the respondents for early initiation of BF was to make sure that the infant received colostrum and food. Respondents reported that mothers are aware of practicing EBF for the first six months. Newborn baby unable to suck was fed breast milk via syringe after collecting from the mother.
Interviewed mother who had preterm and LBW baby in Meremeyti of southern zone said “at home as traditional belief, I may give butter as initiation of feeding”
Some mothers especially those who gave birth at home were unaware of the advantage of colostrum then they discarded it because they believed that the newborn baby’s stomach is unable to digest. In most cases babies delivered at hospitals were initiated with formula or cow’s milk especially if the baby is hospitalized in NICU or mother is unable to produce adequate breast milk then baby may start breast feeding after one day. HIV transmission from mother to child is also a concern reflected by some mothers.
Focus group discussant grandmother from Neksege, southern zone explained the condition as “I understand that the major concern of the society is HIV could be transmitted from mother to newborn baby through breast feeding”
Focus group discussant mother who had less than 2yrs children in Guya of central zone mentioned “In previous time, if a mother could not produce enough breast milk, the baby was breast fed by other’s breast milk (sister, grandmother, relative or neighbor)”
Cord care
Mothers reported that it was important to apply substances to the cord to quicken the healing. The commonly used substance was butter even though most of them believed that this is a harmful traditional practice. Focus group discussant mother who had less than 2yrs children in Guya, Central zone said “I do not apply anything except prescribed medication to the cord, it will dry by itself”
Family experience when neonate /child is hospitalized
Most Respondents reflected that Social factors could also impact parental participation in newborn care including: parental income (financial problem), household domestic responsibilities as mothers play the most active role in rearing children. When house hold responsibility is taken care of by the mother, she tends to be stressed, because children may be absent from school, starved. Mother become worried about such conditions, family members get affected psychosocially. Some mothers get support from Neighbors, grandmother, husband in taking care of the baby when she is hospitalized for prolonged period.
Care provision and Health Education
All respondents repeatedly mentioned that mothers received health education mainly from health professionals (HEWs, midwifes, nurses, physicians), Women Development Army (WDA) and grandmothers. The education is all about newborn care like importance of colostrum feeding, exclusive breast feeding, supplementary feeding, the need & how to keep the baby warm, when & how to bath the baby, cord care.
In health facilities, health care service (care of the baby) is always decided by health professionals and at home the decisions on type of care is mostly by grandmothers and sometimes by husbands.
All respondents acknowledge that most of the time mother is the one who participate mainly in taking care of the newborn baby but grandmother or mother-in-law take more responsibility in supporting the mother to take care of the baby especially if the mother is primigravida. However few fathers in urban area also help the mother in providing care for the baby.
Focus group discussant mother who had less than 2yrs children in Adigudom, Southern zone said “at home the decision about newborn care is mainly made by mother because mother is the one who is taking care of the baby”. Another Focus group discussant mother who had less than 2yrs children in Adigudom, Southern zone said “The community accept the practice done mainly by mother”
Most respondents agree that these days the society believes that parents do seek medical care immediately for tonsillitis or uvulitis. However, there is still traditional uvulectomy practice & treating tonsillitis using herbal medicine among the community especially in rural area.
Harmful traditional practices
Respondents said that some cases babies born at home, feeding may be initiated by sweet (water & sugar or Honey) than by breast milk especially if the mother is unable to produce breast milk. Some mothers believed that traditional uvulectomy is effective than medication in managing uvulitis. They also underlined that health facilities intervention is more effective for male circumcision than traditionally.
Health care professionals’ perspectives on the Newborn care practice
1. Newborn Care practice in Health Centers and at home by HEWs
1.1 Weight measurement
Nearly all participants including health extension workers (HEW) reported that the weight of all babies born at health facilities is measured along with the rest essential newborn care package. However, few Nurses and midwives acknowledged that there is instances where newborns were not measured their weight in some critical situation until the situation becomes managed.
“Sometimes there may be a situation where a newborn is not weighed for 2–3 days. For example, if the baby is hypothermic or very critical, it may be preferred to continue the oxygen and hypothermia treatment rather than interrupting the oxygen to measure weight; it does not matter to the baby whether weighed or not.” (A nurse profession working at NICU in Adigrat Hospital).
Participants reported that HEWs and women Development army (WDA) identify home births then enable mothers to visit health facility and have their babies weighed.
“I do not think babies are weighed at home. They rather come to health facility even at fourth stage. Even if, birth occurs at home, most are not kept at home before being weighed”. (A Midwife from Degua Tembien).
However, nearly all participants stated that newborns delivered at home could not be weighed due to lack of weighing scale. Some of the participants also mentioned that there is lack of awareness about the importance of weight measurement at home both by the community and health professionals (HEWs). Some of HEWs responded that they understand the importance of the weight measurement at home. The same HEWs stated that they have weighing scale and are weighing babies born at home during visit on 24 hours, 3rd day, 7th day and 42 days after delivery for postnatal care purpose. In addition, they reported that there is a growth monitoring schedule monthly at health post. But they affirmed that there is a gap in visiting according to the schedule. HEW from Guya Health Center described the experience of weighing babies by saying “There is no baby who is not weighed. All babies are usually weighed. In previous time simply we used to assess the cord and give Vitamin “A”, but in recent times, we have taken ICCM training in Mekelle, in 2016. Since then, it has got better attention and we started taking weighing scale during home visit and weigh the baby at home”.
HEWs also highlighted that there were many mothers who did not know their babies weight during the home visit. Most (80%) of participants know the right cut point of low birth weight (LBW) which is less than 2.5 kg. and the rest mentioned that LBW is < 2.2 kg. Participants reported that they use variety of methods to calibrate the weight scale. For example, nearly all Midwives and Nurses used pre-calibrated weight, like a bag of Normal saline and one kilogram stone to check the scale. However, few Midwives and Nurses and almost all HEWs used 0 as indicator for calibration of the weight scales.
1.2 Other Essential Newborn cares
Some participants reported that TTC eye ointment application, vitamin k administration, skin to skin contact and thermal care, like wrapping of the baby with dry close and use of sock and hat at health facility are practiced well. They also reported that advice is being given to mothers on how to maintain thermal care; like avoiding bath before 24 hours, wrapping of the baby with thick clothes, importance of frequent breastfeeding and to visit health facility immediately when they observe danger signs of the babies. Participants universally reported the discharge time was after 6 hours of delivery in the absence of any complication. In rural health centers and in non-congested health centers, the discharge time was after 24 hours. However, for mothers who have preterm or LBW baby or other additional maternal and neonatal complication, the discharge time is different from normal situation. Therefore, newborns under kangaroo mother care (KMC) may stay in health facility until the baby becomes stable and able to breastfeed or until the other problems become managed.
2. Existing Strategy to Identify Home Birth and Practice of Post Natal Care at Home
2.1 Methods of Home Birth Identification
70% of births in the region are Facility births. Missing the remaining births (30%) would definitely affect the progress to decrease the existing huge national and regional neonatal mortality (30 and 34 per thousand respectively). All participants universally reported that there is a network system among WDA, HEWs and Midwives. Moreover, each woman with in the WDA, is also networked 1–5 in their catchment. Therefore, WDAs are responsible to survey and report the number of pregnant women in each network to HEWs. Even they can also communicate directly with midwives regarding this issue. According to the participants’ explanation, their main focus was on mobilizing all pregnant women to deliver in health facility. Therefore, during labor time, mainly the family of the women and WDAs are responsible to call either HEWs or directly to ambulance or midwives. A midwife from Abi-Adi Hospital said “To my understanding, when a woman gives birth at home or during onset of labor, information will reach to HEWs through the established network. For example, a woman who gave birth at home in Kola tembien comes to our health center with the help of HEWs. So they have a strong network.”
Most of participants were not denying that many mothers who gave birth at home due to ambulance delay, lack of family around the mother or if they consider they are safe. However, they were investing efforts to bring them to health facility even after delivery for checkup and essential care using the existing network. Acknowledging this effort, still many mothers were not visited at home in instances, where there was meeting, training, due to distance factor and lack of report either from the mother or WDAs. Few participants also marked the existence of gaps in communication between HEWs, Midwives and WDAs. Sometimes; HEWs hear about the home delivery after 2–7 days. HEWs also stipulated that there were some instances where they may not hear about the home birth, if a woman came from out of their catchment area.
A HEW from Alassa kebele described a usual scenario happening in his kebelle as follows “In situations where the pregnant women are living far from their parents, We recognized that the pregnant women continue their ANC follow up in their own nearby health post or other facility but when they reached term, especially if they were nulliparous, they prefer to deliver at kebele where their father or mother lives in to get better social support. Nowadays, we have started to inform the HEWs found in that kebele by telephone if that kebele is in the same district. However, if they are out of the same kebelle, it was difficult for us to follow such women….this is a usual scenario happening with us.”
Participants emphasized on importance of continuing the existing strategies (Network) in identifying home birth. However; increasing the number of HEWs and strengthening of the already established network between WDA and HEWs deserves to be given attention. In addition, few participants also recommended to create awareness on the risk of home delivery in community and to train HEWs how to maintain thermal care and implementation of KMC at community level. A midwife from Alassa health center p3 explained the status of the facility “The main problem is absence of bed rooms in maternity waiting rooms. Had this precondition fulfilled many mothers would have stayed here with us since fourth visit of ANC. Moreover, there is no food provision in the health center, so many mothers leave to their home. If this is not resolved, home delivery will continue and identification of home born babies may not be easy.”
2.2 PNC at home by HEWs
In rural areas, HEWs were responsible to provide postnatal care at home after delivery. In principle, they have a schedule when to visit home to home however according to their explanation they are not strictly following this schedule due to meeting or training. For example, they are supposed to visit on 24 hours, 3rd day, 7th day and 42 days after delivery. Their visit was inconsistent. Few mentioned that there was time when they could not visit until 2 weeks. Some of the HEWs reported that midwives were expected to cover these activities when the HEWs are not available. Midwives and Nurses working at hospital reported that they are not expected to offer PNC at home but they mentioned that they advise mothers at discharge to revisit the health facility for PNC based on the schedule. Based on the participants’ description, the most common practice for postnatal care at home by HEWs were cord observation for bleeding, weight measurement, breastfeeding assessment, and assessing danger signs.
3: Referral system for Newborns
3.1 Reason for referral
The most frequently mentioned reason for referral from the lowest to highest health facility were; Preterm and LBW babies, unable to breastfeed, breathing difficulty, and congenital malformation. Few participants from health center also mentioned additional reasons such as “no improvement after KMC”, umbilical cord complications, jaundice, sepsis and vomiting everything. Midwife from Bizet health center p2 described the referral condition of the facility “If the service is not available here and if we consider that they will be better served there, we will refer them. Now for example, if Preterm or LBW baby didn’t improve after KMC, could not take expressed milk, we refer the baby to higher hospital to be fed by Nasogastric Tube”
3.2 Referral Chains and Challenges around the Referral System for Newborn
The referral system was implemented in both directions from lower to higher and vise-versa. Referral from higher to lower level facility is meant for follow up purpose particularly, from health centers to health posts (HEWs). More than half of the participants mentioned that during referral of a sick baby, providers accompany the baby along with his mother using ambulance in most of referrals. But two hospitals mentioned that sometimes there was limitation in routine availability of ambulance service because they don’t have their own ambulance. A nurse working in NICU from Adigrat Hospital described about ambulance service “We use ambulance from the town administration for referral when we have a case. I believe, this has to be improved. The hospital should have its own ambulance. There is time when this ambulance service is interrupted, then we are forced to send them with public transport. The nursing mother may be socked with blood, there is neonate and her family, and it is distressing to send them with public transport. You can imagine that how it is difficult including the expense for transport”
Nearly all HEWs and few midwives mentioned that they used referral slip to refer a baby. Only two participants mentioned that they apply thermal care and breastfeeding on the way to referral center. It was also reported that the chain of referral linkage is from HEWs at health post to health center (HC) and from HC to Hospital or directly individuals can visit HC and hospital. A Nurse working at Neonatal Intensive Care Unit (NICU) described the challenges in referral system as follows: “Some institutions refer a baby without a problem to hospital. I doubt, the delivery service workers, that they are well capacitated. Most Health officers or Midwives lack skill for good attachment during breastfeeding, they refer many neonates with a reason of unable to suck or early neonatal sepsis. But we are not denying that some institutions refer babies with real problems that has to be managed at hospital level. Over all there is a problem in the referral system”.
The down ward referral system from health center to HEWs seems better as compared to from hospital to health center. According to the midwives and HEWs explanation, there were green and yellow cards which were given to mothers during discharge to link them with HEWs and Women Development Army respectively for follow up and postnatal care. In addition to this, HEWs reported that the midwives sometimes inform them by telephone to follow the mother with her baby after discharge. But few participants acknowledge that some women might keep silent while the card is in their hand. Moreover, participants from both hospital and health center also reported that there was no feedback from hospitals to health center.
4: Health problems and recommended care for Preterm and LBW babies
4.1 Health problems associated with Preterm and LBW babies
The most frequently mentioned possible problems are associated with preterm birth (PTB) and LBW babies were; unable to suck, breathing difficulties (Respiratory distress syndrome), Hypothermia, and sepsis. Hypoglycemia, pneumonia, malnutrition, jaundice and weak baby also reported as complication of PTB and LBW by few respondents.
4.2 Knowledge of health care providers on Preterm and LBW babies
Numerous important issues were mentioned by participants regarding the recommended types of care for Preterm and LBW babies. The frequently mentioned care were; breastfeeding for those who can suck/NG tube feeding with expressed milk, KMC or skin to skin contact (SSC), and use of Heater/incubator for thermal care. In addition, few participants also mentioned the importance of hygiene, sock, thick towel, and hat to prevent hypothermia, temperature measurement, formula feeding when the woman is unable to produce milk and follow up. A Nurse who works at NICU in Mekelle Hospital explained about newborn feeding: “Sometimes mothers may not have breast milk and they may feed formula milk. Scientifically, breast milk is the recommended one but when the mother doesn’t have breast milk, she’ll be forced to use formula milk”.
4.3 Actual practice around the care of Preterm and LBW babies
Almost all midwives and nurses reported advising mothers on frequent breastfeeding, exclusive breastfeeding, the importance of KMC. They also reported expression of breast milk and feeding the babies with syringes and nasogastric tube when direct breastfeeding is not possible (baby unable to suck). However, some of the participants reported that they were using formula milk to feed the newborns when they encounter a woman with difficulty of breast feeding even though they understand this practice is not recommended scientifically. They also use hat, sock, and cotton clothes during thermal care practice provided by the mother from home and sometimes from the health facility even though most facilities did not have linen available for this purpose. They also reported preterm and LBW babies got essential newborn care like vitamin k and TTC eye ointment as term babies. A midwife, from Kasech Health Centre described about preterm newborn care “If the newborn is premature we will apply KMC immediately after delivery and we advise her to continue this practice at home.”
Another Nurse who works in NICU at Adigrat hospital explained about NICU care provision “Here in this department all things are serious and implemented accordingly, all of us are well trained & accountable for any activity we do in NICU.”
A HEW from Neksege Health Centre explained about facility discharge advice “Since I am working outside of the health center I am not sure that what has been done inside the health center. However I can be sure that most mothers have awareness about the importance of skin to skin contact and frequent breastfeeding because I meet them in the health post after they are discharged from the health center. If there is frequent breastfeeding the baby will increase in weight, and he/she become strong.”
5: Challenges encountered by health workers during provision of Newborn care service
Participants overwhelmingly mentioned that they have shortage of sock, hat and towels during care of preterm and LBW even though pregnant mothers are advised to bring their own during ANC as part of birth preparedness and complication readiness. They also reported that most women having preterm or LBW baby prefer to go home before they achieve the KMC discharge criteria. Service providers were also challenged by shortage of electric power, phototherapy machine, and lack of awareness on the community side on preterm and LBW care. A health officer from Bizet health center described about shortage of clothes for newborns “In previous time materials like sock, hat and towel were donated by nongovernmental organization (NGO) to our health center. Even though we advise mothers during ANC to bring these materials, many mothers still don’t this one.”