Immediate newborn care and breastfeeding: EN-BIRTH multi-country validation study

Abstract

Background Immediate newborn care (INC) practices, notably early initiation of breastfeeding (EIBF), are fundamental for newborn health. However, coverage tracking currently relies on household survey data in many settings. “Every Newborn Birth Indicators Research Tracking in Hospitals” (EN-BIRTH) was an observational study validating selected maternal and newborn health indicators. This paper reports results for EIBF. Methods The EN-BIRTH study was conducted in five public hospitals in Bangladesh, Nepal, and Tanzania, from July 2017 to July 2018. Clinical observers collected tablet-based, time-stamped data on EIBF and INC practices (skin-to-skin within 1 h of birth, drying, and delayed cord clamping). To assess validity of EIBF measurement, we compared observation as gold standard to register records and women’s exit-interview survey reports. Percent agreement was used to assess agreement between EIBF and INC practices. Kaplan Meier survival curves showed timing. Qualitative interviews were conducted to explore barriers/enablers to register recording. Results Coverage of EIBF among 7802 newborns observed for ≥1 h was low (10.9, 95% CI 3.8–21.0). Survey-reported (53.2, 95% CI 39.4–66.8) and register-recorded results (85.9, 95% CI 58.1–99.6) overestimated coverage compared to observed levels across all hospitals. Registers did not capture other INC practices apart from breastfeeding. Agreement of EIBF with other INC practices was high for skin-to-skin (69.5–93.9%) at four sites, but fair/poor for delayed cord-clamping (47.3–73.5%) and drying (7.3–29.0%). EIBF and skin-to-skin were the most delayed and EIBF rarely happened after caesarean section (0.5–3.6%). Qualitative findings suggested that focusing on accuracy, as well as completeness, contributes to higher quality with register reporting. Conclusions Our study highlights the importance of tracking EIBF despite measurement challenges and found low coverage levels, particularly after caesarean births. Both survey-reported and register-recorded data over-estimated coverage. EIBF had a strong agreement with skin-to-skin but is not a simple tracer for other INC indicators. Other INC practices are challenging to measure in surveys, not included in registers, and are likely to require special studies or audits. Continued focus on EIBF is crucial to inform efforts to improve provider practices and increase coverage. Investment and innovation are required to improve measurement.

Barriers and enablers to routine register data collection for newborns and mothers: EN-BIRTH multi-country validation study

“…The qualitative data analysis presented in this paper identified common barriers and enablers for labour ward register recording across all indicators, using health worker and data collector responses together. Indicatorspecific mixed-methods linked analyses will be presented in other linked papers to further explore subthemes and differences between cadres [57][58][59][60][61][62]. It was beyond the scope of this study for the EN-BIRTH data collectors to directly observe or measure the detailed process of register filling (e.g.…”

Initiation of Breastfeeding in Low- and Middle-Income Countries: A Time-to-Event Analysis

“…24 Although women's reporting of EIBF overestimate observed EIBF, self-report still accurately reflects that early breastfeeding is more common among vaginal deliveries than cesarean deliveries. 36 Our study attempted to minimize recall bias to the extent possible by restricting the analysis to the most recent birth in the past 2 years. Our study also assumes the midpoint of the interval reported, which may result in additional bias; however, for the majority of women who reported breastfeeding with 1 hour, shifting coding from 0 hours to 0.5 hours may more accurately reflect the timing of early initiation as babies progress through several initial phases of first relaxing, awakening, and activity before suckling.…”

Equity in newborn care, evidence from national surveys in low- and middle-income countries

“…Additionally, survey-based measurement of coverage of care is subject to the ability of respondents to understand the questions and accurately report the answers. Results from validation studies of some newborn care survey questions have shown inconsistent results [52][53][54][55][56][57][58]. In Kenya and Swaziland, for example, interventions such as counselling on breastfeeding and danger signs in the newborn met criteria for accuracy and bias while interventions such examining the baby did not [55].…”