Skin-to-skin contact is one of the eight proven effective ENC interventions that improve newborn survival(9, 21). The prevalence of reported SSC practices was low at 28% in ten surveyed districts in Bangladesh. Results from our multivariable model identified two critical positive factors for improving SSC practices; i) facility delivery and ii) ANC from MTPs. In contrast, cesarean delivery significantly reduces the practice of SSC in facilities. Researchers, program implementers, and policymakers need to consider these determinants when identifying and designing essential interventions to improve SSC practices at the population level.
Despite being an easy and no costs intervention with enormous benefits, SSC is one of the least used ENC practices in developing countries(15, 17, 22, 23). Our findings reiterate this evidence for 10 surveyed districts in Bangladesh. A similarly low prevalence of SSC practices was reported in previous studies in Bangladesh, which showed a prevalence between 26% and 30%(18, 24). Our reported prevalence of SSC is higher than the reported prevalence in India (14.5%), Nepal (16.5%), Tanzania (9.7%), and Ethiopia (24.3%). It is lower than the reported prevalence in Sri Lanka at 50% and the Gambia at 35.7% (24–28). The low prevalence of SSC practices in these developing countries could be attributed to various factors such as the high burden of home deliveries, low ANC coverage, availability of community-based interventions, and sociodemographic and health system factors(24, 25, 27–29).
One striking finding of our study is that mothers who delivered in the facilities have a higher likelihood of SSC practices compared to the mothers who delivered at home. Previous studies from Bangladesh, Gambia, and Ethiopia also found facility delivery to be a significant positive predictor of SSC practices (7, 27, 28). Although Bangladesh is observing an increasing trend in coverage of facility deliveries, 50% of women are still delivering at home(6). This finding highlights the need for increasing coverage of facility delivery as well as improving SSC practices after home deliveries in Bangladesh. Lack of awareness, social norms, distance to the facilities, lack of transport facilities, cost of care-seeking, and poor quality of care are some of the key barriers preventing women from delivering in facilities in rural areas of Bangladesh(30–35). Alliance for Maternal and Newborn Health Improvement (AMANHI) project implementing 24/7 obstetric services, training of the health care providers, community advocacy, comprehensive birth planning counseling, financial incentives for covering delivery costs, and emergency referral transport in Sylhet Division of Bangladesh, significantly improved coverage of facility deliveries from 25–78% in the intervention areas (36). Policymakers and health programmers need to consider a similar integrated package of interventions addressing both supply-side and demand-side barriers to improve coverage of facility deliveries in this setting.
On the other hand, to improve SSC practices after home deliveries, community-based interventions such as community skilled birth attendants (CSBA) and community demand generation activities may play a significant role. Community-based maternal and newborn health package piloting in Bangladesh, Malawi, Nepal, and India showed significant improvement in all four ENC practices including SSC (25, 29). The study deployed trained community health workers/ volunteers for regular home visits during and soon after delivery. Community health workers/ volunteers provided routine maternal and newborn care, promoted routine health service utilization, supported birth preparedness, conducted counseling on danger signs and essential newborn care, and identified and referred women and newborns having maternal and newborn danger signs to the nearest health facilities during regular home visits. Although community-based interventions showed some positive impact on ENC practices, considering very low coverage of SBA among home deliveries (3%) in Bangladesh and resource-intensive nature of the community based maternal and newborn health programming, the question remains “which investment will bring maximum impact on SSC practices in these resource-limited settings; facility delivery or home delivery or both?”(20, 24)
Another important finding of our study is that despite having a significant positive association of facility delivery on SSC practices, less than half of the women who delivered in the facilities reported SSC. This signifies that increasing coverage of facility delivery alone will not be able to bring the change in SSC practices without improving its practices in the facilities. Shortage of skilled workforce, lack of time, difficulty in assessing eligibility for SSC, interference with routine procedures after birth, lack of motivation among the mothers and family members, and cultural practices were identified as some of the major barriers in implementing SSC after facility deliveries(37–39). WHO and UNICEF recommend implementation of the baby-friendly hospital initiatives to improve SSC and breastfeeding practices through training of the health care providers and creating an enabling hospital environment such as a standard guideline on SSC, availability of skilled workforce, and availability of sufficient postnatal beds with the provision of privacy (12, 40). The Government of Bangladesh has already started the implementation of baby-friendly hospital initiatives in public health facilities. Experience from implementation showed a significant positive impact on improving SSC and early initiation of breastfeeding practices in several other settings(41, 42). Additionally, strengthening monitoring and adoption of essential measures to address the barrier and challenges of implementing SSC in the facilities using the Plan-Do-Act-Check (PDCA) model may improve SSC practice in facilities(43–45). Save the Children’s MaMoni MNCSP project has recently started implementing the PDCA model for improving ENC practices including SSC in the public health facilities of Manikganj and Madaripur district of Bangladesh. Evaluation of this PDCA model will generate evidence on the effectiveness of this intervention in improving SSC practices in the local contexts.
Our result showed that having a cesarean delivery reduced the likelihood of receiving SSC by 36% compared to the mothers having a vaginal birth. Findings from other studies also suggested a negative impact of cesarean section on SSC practices and early initiation of breastfeeding(11, 46–50). WHO recommends starting SSC immediately (if possible in the operation theater ) after cesarean delivery as soon as the mother regains consciousness in the absence of any precarious complications (12). As uncomplicated cesarean deliveries are performed using spinal anesthesia where mothers remain conscious at the time of operation, SSC can be initiated in the operating theater. Two different intervention modalities such as the Plan, Do Study, Act (PDSA) model and Practice Reflection, Education, and training, Combined with the Ethnography for Sustainable Success (PRECESS) model showed a significant improvement in SSC practices after cesarean births (51–54). The PDSA model piloted SSC in the operation theater using a flow chart and developed a monitoring and feedback mechanism to address the barriers and challenges of implementation. The PRECESS project educated the staff on standard steps of SSC implementation created a staff monitoring mechanism on SSC after cesarean births and shared videos with mothers on SSC (51, 52). One limitation of these studies is that the sample sizes are small. Contextual adaptation of these evidence-based interventions must be tested using a rigorous implementation research design, with a sufficient sample size for generating strong evidence on the efficacy of these interventions in the local context.
Another challenge in improving SSC practices in Bangladesh is the low coverage of SSC in private and NGO facilities. High rates of cesarean deliveries in private facilities (85%) and NGO facilities (45 %) could be the reason for low SSC practices. Our national-level data also showed that 84% of women who delivered in the private facilities had a cesarean Sect. (20). The WHO threshold of optimal cesarean section rates for any country is 15% which signifies that unnecessary cesarean deliveries are happening mostly in the profit-driven private sectors(55). It’s crucial to implement proven interventions including accreditation of private facilities, implementation of Robson’s classification, and the second review to regulate cesarean sections in the private facilities (56–58). In essence, implementing programs to initiate SSC after cesarean sections in the operating theater along with optimization of cesarean deliveries are necessary to bring about the potential improvement in SSC practices.
Our study also showed that mothers having one to three ANC visits and four or more ANC visits (at least one from an MTP) had better reported SSC practices. Our finding is consistent with previous studies in Bangladesh, Gambia, and Ethiopia. Our finding is consistent with previous studies in Bangladesh, Gambia, and Ethiopia(7, 27, 28). ANC has the potential to improve SSC practices in two ways. Firsts, ANC is an important predictor of facility delivery and it is evident from our findings that facility delivery improves SSC practices (59–62). Second, lack of motivation among the mother and the family members is a potential barrier to SSC practices(37, 39). Recent evidence identifies ANC counseling as a potential opportunity for motivating mothers for uptake of SSC(37).
This study has the following limitations. First, we used mothers' self-reported data for defining SSC practices. Previous studies reported mixed evidence on the validity of using mothers' reported data for defining SSC compared to observation-based data (63, 64). However, observation-based data collection is expensive and not feasible during population-based surveys. Additionally, we found that major national-level population-based surveys such as DHS in Bangladesh and Nigeria collect mothers’ reported data for defining SSC and we adopted questions from BDHS for defining SSC in this study [7]. We recommend further exploration to identify appropriate wording for defining SSC during population-level surveys and to collect more in-depth information regarding the actual timing of the start and duration of SSC to improve validity. Second, recall bias may also be an issue which we tried to address by interviewing women with shorter recall periods in this survey(20).
Despite the limitations, our study is unique in terms of generating evidence on the prevalence and factors associated with SSC practices, which are not often studied at a population level (18). It is crucial to know the population-level estimates of SSC and to understand the factors influencing its practices, to better understand the barriers to its uptake, and what can be done to improve coverage of the practice in the local context.