Participant information
A total of 39 mothers were recruited across the six facilities for at least one observation period; 31 mothers during labour and delivery, 31 mothers during post-natal period at the HCF, and 30 mothers at home. Eight mothers dropped out of the study after childbirth and post-natal care observations at the HCF; and an additional 7 participants were recruited for facility discharge and home observations.
Mothers had similar characteristics across the observations (Table 1). All participating mothers reported they were married with a mean age of 30 and 2 previous births. Fathers were present in 26/31 post-natal care observations and in 28/30 home observations.
[TABLE 1]
POSTNATAL CARE
WATER, SANITATION, AND HYGIENE FACILITIES
Functioning handwashing facilities with soap were available in 2 of the 6 post-natal care wards; however, no material for hand drying was present. There was no other provision for handwashing within any of the post-natal care wards e.g. alcohol-based hand rub.
HAND HYGIENE OPPORTUNITIES AND ACTION
A total of 291 hand hygiene opportunities were observed during the post-natal period, 27% related to maternal care (79/291) and 73% related to newborn care (212/291) (Table 2).
[TABLE 2]
Visitors accounted for 37% (103/291) of all observed hand hygiene opportunities. The majority (95%) of visitors’ hand hygiene opportunities were during newborn care activities. The remaining observed hand hygiene opportunities were among HCW (29%), mothers (21%), fathers (13%) and cleaners (2%).
Across all actors, no hand hygiene action was observed in relation to 91% (265/291) of hand hygiene opportunities. Half (13/26) of all observed hand hygiene actions were by HCW and the other half (13/26) by mothers. No hand hygiene actions were conducted by fathers, visitors, or cleaners. Only 3 of 26 hand hygiene actions observed were categorized as adequate (handwashing with soap and water) - once by a HCW during maternal care and twice by mothers during newborn care. The remaining 23 hand hygiene actions were inadequate, and included HCWs wearing gloves without washing hands with soap prior to glove use (12/26) and mothers rinsing hands with water only (11/26). Among HCW, half (6/12) of inadequate hand hygiene actions were during maternal care - mostly prior to IV related procedures including cannula insertion, changing IV therapy bags and inspecting the IV cannula site. Of the 212 hand hygiene opportunities observed during newborn care, 8% (17/212) were related to cord contact and the rest (195/212), were during other contact with the newborn (Table 3).
[TABLE 3]
Cord contact in the post-natal care ward was made by multiple actors - mothers, HCWs, cleaners and visitors. The majority (13/17) of cord contact hand hygiene opportunities happened prior to cord cleaning and the rest (4/17) were during umbilical cord stump inspections. Across the 17 cord contact hand hygiene opportunities observed, hand hygiene actions were conducted 5 times, all of which were prior to cleaning of the newborn’s cord. Only 1/5 of hand hygiene actions was adequately performed.
Discharge
The average length of stay after birth across all six facilities was 35 hours (range: 7 – 96 hours). Standardized discharge procedures were reported in all but one HCF. Key informants reported that discharge procedures included specific health information that should be provided to mothers at the time of discharge. However, 9/33 mothers did not receive any discharge advice at all from the midwives (Table 4).
[TABLE 4]
When given, discharge advice covered both maternal and newborn care. Information on hand hygiene, typically related to newborn care; specifically cord care, baby handling and breastfeeding. During observations, approximately half (17/33) of mothers received advice on washing their hands before handling the baby and 70% (23/33) received information on clean cord care, including washing hands before and after applying chlorohexidine, applying chlorohexidine exclusively on the cord, and placing the cord outside the diapers. However, in follow-up qualitative interviews, the only hand hygiene related discharge information that mothers could recall was involving breast feeding practices.
… First and foremost, I was told that it is not good for a breastfeeding mother to keep long nails, that it harbours dirt and that it is dangerous to the baby. Secondly, I must wash my hands before I breastfeed the baby. In fact, I must make sure that the environment where the baby stays is very clean. – Mother, tertiary facility
HOME OBSERVATIONS
The average duration of home observations was 5.1 hours (range: 2.4 – 6.8 hours) with an average of 101 hand hygiene opportunities recorded per observation (range: 30 – 180). Home observations started an average of 4 hrs after discharge from the facility (range: 0 – 21). Three out of thirty women where observed more than six hours post discharge.
WATER SANITATION AND HYGIENE FACILITIES
Half (16/30) of households had access to a water source within the home, 7 had access to an on plot water source, and 7 used a public shared water source. The majority (27/30) of households had stored water within their household at the time of the observation, and all but one (29/30) had soap at the household. Of the 30 households visited, 21 had a private latrine, 8 had access to a latrine shared with other households, and 1 did not have access to a latrine. Two-thirds of households (20/30) had a handwashing facility within the compound, but only 9 households with a handwashing facility had soap or another cleansing agent present at the site. There was an average of 15 non-parental caregivers observed across household observations (range: 3 - 39). Non-parental caregivers included household members, visiting relatives, and other visitors.
HAND HYGIENE: OPPORTUNITIES AND ACTION
All interviewed mothers knew both when and how hands should be washed in the home environment:
Before carrying my baby, I wash my hand, before carrying her and anytime I go to the toilet, I wash my hand before carrying my baby, even if I go to the kitchen to cook, I wash my hand even if I just go to urinate I wash my hand before carrying my baby. – Mother, secondary facility
When I want to take care of the cord, I will wash my hand because I will be bathing the baby. I will wash my hand before I carry the baby for bathing. – Mother, primary facility
However, this knowledge was not reflected in practice. Of the 459 hand hygiene opportunities observed in the home environment, only 1% (5/459) was followed with adequate hand hygiene action and hands were rinsed at another 3% (12/459) of hand hygiene opportunities (Table 5). Mothers conducted the majority (15/17) of the hand hygiene actions.
[TABLE 5]
Cord contact accounted for 6% (29/459) of all hand hygiene opportunities; the majority (22/29) related to cord cleaning. Adequate hand hygiene was observed during 2 of 29 cord contact-related hand hygiene opportunities.
Non-maternal caregivers performed a variety of activities in the household, many of which put them at potential risk of transmitting infections to newborns during caregiving [see Additional File 1]. Over half of newborns (19/30) were bathed within the first six hours of their arrival to the home and bathing often involved multiple non-maternal caregivers. In one household, a newborn was bathed by 6 different non-maternal caregivers during the observation period. Following bathing, 8/19 newborns were rubbed with oils, in some cases mixed with different substances including; cassava flour mixed in red oil; black soap; palm kernel oil; shea butter; garlic and raw egg.
Despite the clear role of non-maternal caregivers in newborn care, mothers reported that asking any caregivers beyond fathers to wash hands was not feasible. Mothers noted that the caregivers would ‘not be happy’ or that they would ‘become angry’ if they were asked to wash their hands:
Some visitors are in a haste, when they come they do not wash their hand, they carry their baby, after they go – [if asked to wash hands] they will become angry. - Mother secondary facility
I can’t tell visitors like that! - Mother, tertiary facility
Some mothers, however described strategies for protecting their newborn, mostly by using the baby wrap as a physical barrier between the skin and the non-parental caregivers’ contaminated hands.
If I ask them to wash their hands, I don’t know what they will feel! That is why I cover my baby with a towel before they carry my baby - Mother, primary facility
He is already dressed and covered with a towel so their hand will not touch the baby’s skin - Mother, primary facility