Background Despite recent improvements in child survival, neonatal mortality continues to decline at a slower rate and now represents 47% of under-five deaths globally. The World Health Organization developed core indicators to better monitor the quality of maternal and newborn health services. One such indicator for newborn health is “the proportion of newborns who received all four elements of essential care”. The four elements are immediate and thorough drying, skin to skin contact, delayed cord clamping, and early initiation of breastfeeding. Although there is existing evidence demonstrating an association with decreased neonatal mortality for each element individually, the cumulative impact has not yet been examined. Methods This analysis uses data from a randomized trial to examine the impact of sunflower versus mustard seed oil massage on neonatal mortality and morbidity in the Sarlahi district in Southern Nepal from 2010 to 2017. The proportion of newborn infants receiving an intervention was the exposure and neonatal mortality was the outcome in this analysis. Neonatal mortality was defined as a death between three hours and less than 28 days of age. Associations between neonatal mortality and the essential elements were estimated by Cox proportion hazards models. The hazard ratios and corresponding 95% confidence intervals were reported. Results 28,121 mother-infant pairs and 753 neonatal deaths were included. The percent receiving the individual elements ranged from 19.5% (skin to skin contact) to 68.2% (delayed cord clamping). The majority of infants received one or two of the elements of essential care, with less than 1% receiving all four. Skin to skin contact and early initiation of breastfeeding were associated with lower risk of neonatal mortality (aHR = 0.64 [0.51, 0.81] and aHR = 0.72 [0.60, 0.87], respectively). The risk of mortality declined as the number of elements received increased; receipt of one element compared to zero was associated with a nearly 50% reduction in risk of mortality and receipt of all four elements resulted in a 72% decrease in risk of mortality. Conclusions The receipt of one or more of the four essential elements of newborn care was associated with improved neonatal survival. The more elements of care received, the more survival improved.

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Objectives This study's primary objective is to examine the validity of maternal recall of iron folate supplementation during antenatal care and factors associated with accuracy of maternal recall. Methods A longitudinal cohort design was employed for the validation study. The direct observation of all iron folate supplementation (IFA) received during all antenatal care visits at the five study health posts served as the “gold standard” to the maternal report of IFA received collected during a postpartum interview. Individual-level validity was assessed by calculating indicator sensitivity, specificity and area under the receiver operating curve (AUC). The inflation factor (IF) measured population-level bias, comparing the true coverage to the survey measure (maternal report) coverage of IFA. A multivariable log-binomial model was used to assess factors associated with accurate recall. Results The majority (95.8%) of women were observed receiving IFA during pregnancy. Women overreported the number IFA tablets received compared to what was observed during ANC visits. On average the reported number of tablets received was 45 tablets greater than the number observed. Individual-level accuracy of maternal report of any IFA receipt was moderate (AUC = 0.60) and population bias was low (IF = 1.01). However, the individual-level validity was poor across the seven IFA tablet count categories; the AUC for categories ranged from 0.47 to 0.58, indicating a performance that at best was slightly better than a random guess and at worst, misleading. Driven by the trend of maternal overreport, the inflation factor indicated that the survey measure drastically underestimated the prevalence of lower tablet categories and overestimated the prevalence of higher tablet counts. Accuracy of maternal report was not associated with months since last ANC observation nor any maternal characteristics. Conclusions Maternal report of the amount IFA supplementation received during pregnancy produced extremely biased population prevalence and performed comparably to or worse than a random guess for individual level validity. It's imperative to improve this indicator for future use, as it is included in global frameworks, initiatives and national program planning. Funding Sources This research was funded by the Bill and Melinda Gates Foundation.

The delivery of nutrition-related interventions and counselling during antenatal care is critical for a healthy pregnancy for both mother and child. However, the accuracy of maternal reports of many of these services during household surveys has not yet been examined. Our objectives were to assess the validity of the maternal reports of 10 antenatal nutrition interventions, including counselling, and examine associates between maternal characteristics and accuracy. Maternal report of services received collected during a post-partum survey was compared to the gold standard, the direct observation of all women's antenatal care visits. Individual-level validity was assessed by calculating indicator sensitivity, specificity and area under the operating curve (AUC). The inflation factor (IF) measured population-level bias. For five indicators, the high true coverage limited our ability to assess the validity of the maternal reports. There were no indicators that had both high individual-level validity (AUC > 0.70) and low population bias (0.75 < IF < 1.25). Indicators with greater true coverage estimates had higher sensitivity and lower specificity estimates compared to those indicators with lower true coverage. There were no maternal characteristics associated with the accuracy of the report. Maternal report of antenatal nutrition-related interventions and counselling during household surveys was found to have variable validity across indicators. Additional research in settings with varying coverage levels should be considered to best inform antenatal care coverage measurement in household surveys.