Keeping newborns warm: beliefs, practices and potential for behaviour change in rural Ghana

Objectives This study aimed to collect data on thermal care practices in rural Ghana to inform the design of a community newborn intervention. Methods All 635 women who delivered in six districts in Ghana in the first 2 weeks of December 2006 were interviewed about immediate newborn care. Qualitative data on thermal care practices and barriers and facilitators to behaviour change were collected from recently delivered/pregnant women, birth attendants/grandmothers, and husband through birth narratives, in-depth interviews and focus group discussion. Results Respondents knew that keeping the baby warm was essential for health but 71% of babies born at home had delayed drying, 79% delayed wrapping, 93% early bathing and 10% were placed skin-to-skin. Birth attendants were usually in charge of mother and baby immediately after birth. Delays in drying/wrapping were linked to leaving the baby unattended until the placenta was delivered. Early bathing was linked to reducing body odour in later life, shaping the baby’s head, and helping the baby sleep and feel clean. Respondents thought that changing bathing behaviours would be difficult, especially as babies are bathed early in facilities. The concept of skin-to-skin care was easily understood and most women said they would try it if it was good for the baby. Conclusion Thermal care is a key component of community newborn interventions, the design of which should be based on an understanding of current behaviours and beliefs. Formative research can help select focus behaviours, decide who to include in interventions, ensure consistent messages and determine what messages and approaches are needed to overcome behaviour change barriers. Maintenir les nouveau-nés au chaud: croyances, pratiques et possibilités de changement des comportements dans les régions rurales du Ghana Objectifs: Cette étude recueille des données sur les pratiques de soins thermiques dans les zones rurales du Ghana afin d’éclairer sur la conception d’une intervention communautaire pour le nouveau-né. Méthodes: Toutes les 635 femmes ayant accouché dans 6 districts du Ghana au cours des 2 premières semaines de décembre 2006 ont été interrogées sur les soins néonataux immédiats. Les données qualitatives sur les pratiques de soins thermiques et les obstacles et facilitateurs d’un changement de comportement ont été recueillis auprès des femmes enceintes ou ayant récemment accouché, les assistantes à l’accouchement, les grands-mères et les maris, par des récits de naissance, des entretiens approfondis et une discussion de groupe focalisée. Résultats: Les répondants savaient que garder le bébé au chaud est essentiel pour la santé, mais pour 67% des bébés nés à la maison un retard dans le séchage a été observé, pour 76%, un retard dans l’emballage, pour 93% un bain trop tôt et 10% ont été placés en contact direct avec la peau. Les assistantes à l’accouchement étaient généralement en charge de la mère et du bébé immédiatement après la naissance. Les retards dans le séchage/emballage étaient liés au fait de laisser le bébé sans attention jusqu’à l’expulsion du placenta. Le bain trop tôt était liéà la volonté de réduire l’odeur corporelle plus tard dans la vie, de façonner la tête du bébé et de l’aider à dormir et à se sentir propre. Les répondants estimaient que changer les comportements du bain serait difficile, d’autant plus que les bébés sont baignés tôt dans les services. Le concept de mettre le bébé en contact direct avec la peau a été facile à comprendre et la plupart des femmes ont dit qu’elles l’essaieraient si cela était bon pour le bébé. Conclusion: Le soin thermique est un élément clé des interventions communautaires pour le nouveau-né, dont le concept devrait être fondé sur une compréhension des comportements et convictions actuelles. La recherche formative peut aider à choisir des comportements précis, décider qui inclure dans les interventions, assurer des messages cohérents et déterminer quels messages et approches sont nécessaires pour surmonter les obstacles au changement de comportement. Manteniendo a los neonatos calientes: creencias, prácticas y potencial para un cambio de comportamiento en Ghana Objetivos: Este estudio recoge datos sobre prácticas de cuidados y control térmico de neonatos de Ghana rural, con el fin de poder informar sobre el diseño de intervenciones comunitarias en recién nacidos. Métodos: Todas las 635 mujeres que dieron a luz en 6 distritos en Ghana durante las primeras 2 semanas de Diciembre del 2006 fueron entrevistadas sobre los cuidados inmediatos proveídos a los neonatos. Mediante narraciones del parto, entrevistas a profundidad y discusiones focalizadas en grupo con mujeres recién paridas / embarazadas, comadronas / abuelas, y maridos, se recolectaron datos cualitativos sobre prácticas de cuidados térmicos, barreras y facilitadores para el cambio de comportamiento. Resultados: Quienes respondían sabían que mantener caliente al niño era esencial para preservar su salud pero un 67% de los bebés nacidos en casa fueron secados con retardo, 76% envueltos con retraso, 93% bañados muy pronto y solo 10% colocados piel-contra-piel. Quienes atendían el parto estaban usualmente encargados tanto de la madre como del bebé inmediatamente después del parto. Los retardos en secar/envolver estaban relacionados con dejar al bebé sin atención hasta que la placenta hubiese sido expulsada. El baño temprano estaba relacionado con reducir el olor corporal en un futuro, darle forma a la cabeza del niño y ayudarle a dormir y sentirse limpio. Quienes respondieron creían que cambiar el comportamiento con respecto al baño sería difícil, especialmente porque los niños son también bañados de forma temprana en los centros. El concepto de cuidado de piel-contra-piel fue fácilmente entendido y la mayoría de las mujeres dijeron que lo intentarían si era bueno para el bebé. Conclusión: El control térmico es un componente clave de las intervenciones comunitarias para neonatos, cuyo diseño debería basarse sobre un entendimiento de los comportamientos y las creencias presentes en la comunidad. La investigación formativa puede ayudar a seleccionar comportamientos focalizados, decidir a quien incluir en la intervención, asegurar un mensaje consistente y determinar que mensajes y enfoques se necesitan para sobreponerse a las barreras que dificultan los cambios de comportamiento. Newborns have difficulty in regulating their temperature and can loose heat rapidly because of their relatively large surface area (Kumar et al. 2009). They are at risk of hypothermia even in tropical climates, especially if they are low birth weight or premature (Kumar et al. 2009; Bhutta et al. 2005). Hypothermia contributes significantly to newborn morbidity (Darmstadt et al. 2005) and is common across diverse settings (Kumar et al. 2009; Bhutta et al. 2005). Prevalence data from Africa are from hospital studies, mostly relate to high risk newborns and have found a wide variation in hypothermia prevalence (22–85%) (Ogunlesi et al. 2008; Byaruhanga et al. 2005; Manji Kambarami Christensson et al. 1995). Data from India suggest that the prevalence of hypothermia in community settings levels may be as high as 45% (Kumar et al. 2009). In Guinea-Bissau hypothermia was associated with a nearly fivefold increase in mortality during the first week of life (Sodemann et al. 2008). Consequently, thermal care is recognized as an essential component of newborn care (Darmstadt et al. 2005). Despite the recognition of the importance of thermal care, there is limited evidence for the efficacy of the individual thermal care practices (Haws et al. 2007) For example, only two randomized studies of early newborn bathing were located. One found no impact of early bathing on hypothermia in a hospital setting with a well-maintained warm chain (Nako et al. 2000). The second found that early bathing resulted in a nearly fourfold increase in hypothermia despite the use of warm water, immediate drying and skin-to-skin care (Bergström et al. 2005). Despite this paucity of data, recommended thermal care includes warming the delivery room, immediate drying after birth, immediate and frequent breastfeeding, delayed bathing, skin-to-skin or close contact with the mother and appropriate dressing/wrapping (Kumar et al. 2009; Bhutta et al. 2005). Evidence from Asia suggests that with well-designed counselling families can change thermal care practices (Kumar et al. 2008; Baqui et al. 2008a; b; Bhutta et al. 2008; Bang et al. 2005). For example, home visit interventions in Bangladesh and India had significant impacts on delayed bathing, raising this from low levels to around 80% (Kumar et al. 2008; Baqui et al. 2008a). The Indian study reported equally impressive increases in wiping the baby after delivery and in skin-to-skin care in the first 24 h (Kumar et al. 2008). More moderate behaviour changes (around 20%) were seen in interventions implemented through government systems (Bhutta et al. 2008; Baqui et al. 2008b). The Asian trials were designed based on an understanding of local practices and beliefs (Kumar et al. 2008; Baqui et al. 2008a); and much has been reported about thermal care practices in Asian settings (Sreeramareddy et al. 2006; Barnett et al. 2006; Baqui et al. 2007; Osrin et al. 2002; Iyengar et al. 2008; Kesterton Khadduri et al. 2008; Darmstadt et al. 2006a,b). Data on local practices are key for designing culturally appropriate and effective newborn care interventions (Neonatal Mortality Formative Research Working Group 2008; Parlato et al. 2004), but there is little information to inform intervention that include thermal care in African settings (Mrisho et al. 2008; Thairu Waiswa et al. 2008). This paper provides qualitative and quantitative data on thermal care in rural Ghana. Data were collected as part of the formative research for a cluster randomized trial implemented at scale that aims to evaluate the impact of a feasible and sustainable home visit intervention (Newhints) on neonatal mortality (Hill et al. 2008). The formative research also included a health facility assessment to determine what activities were required at health facilities to ensure a continuum of care between facilities and communities (Howe LD, Manu A, Tawiah-Agyemang C, Kirkwood BR, Hill Z, submitted). Data were collected from six districts in the Brong Ahafo region of Ghana. The districts cover 12 000 square miles and have a population of 600 000. The populace of Brong Ahafo is overwhelmingly rural with farming being the most important economic activity. Forty-one per cent of women are illiterate. Most villages do not have electricity and can only be reached by dirt roads. Currently, 35% of births occur at home (GSS 2009). At the time of this study around 50% of births were at home as the government scheme to provide free delivery care was not yet fully operational in the study area. Quantitative data were collected through an existing 4 weekly demographic surveillance system by trained community-based field workers (Kirkwood et al. 2010); all data were double entered and checked for consistency. All women (n = 635) who delivered in the study districts in the first 2 weeks of December 2006 were asked about newborn care (including timing of wrapping, drying and bathing, frequency of bathing and where the baby was placed during the first day of life). December is one of the coldest months of the year and is thus the time that newborns are most at risk from hypothermia. The median timing of the interview was 15 days after delivery. Frequency distributions for home births were produced using Stata 8.0 (Stata Corporation, College Station, TX, USA). Qualitative data were collected from three districts between December 2006 and January 2007. Fourteen villages were selected to reflect the study area diversity. The methods are described in detail elsewhere (Hill et al. 2008). Data on current community practices and barriers and facilitators to behaviour change were collected through birth narratives with women who had delivered at home in the last 2 months (25), in-depth interviews (30 with recently delivered/pregnant women, 12 with husbands and 20 with birth attendants/grandmothers) and focus group discussions (two with recently delivered/pregnant women, six with birth attendants/grandmothers, and two with husbands). Narrative and in-depth interviews collected information on personal experiences and beliefs and focus groups collected information that required more discussion such as the potential for behaviour change. Women for the birth narratives were selected from the surveillance system data base. In-depth interview and focus group respondents were located through word of mouth. The focus groups were stratified by age and ethnicity. All sampling was purposive to ensure that respondents had a range of ages, ethnicities, parities, education, and socio-economic status. A wide range of respondents were selected to give a broad understanding of the barriers and facilitators of behaviour change and to understand who influences the behaviours. Informed consent was gained from all participants. Data were collected in the local language, and the sample size for the interviews was determined using saturation sampling. During the interviews, trained fieldworkers took field notes which they converted into detailed English transcripts the same day – a sub sample of interviews were tape recorded for data assurance purposes. All focus groups were recorded and then transcribed into English. The transcripts were explored through multiple readings using a grounded theory were and the data were using 6 and interviews were tape recorded and through in the of this paper are in the first and in the from The prevalence of thermal care behaviours are in per cent of babies born at home had delayed drying after 79% delayed wrapping, early bathing was and skin-to-skin contact was were women who delivered in facilities. Birth attendants for home included birth attendants and attendants were usually by one or two who the mother in the and newborn care and the delivery of the placenta was the birth and the for leaving the baby in the birth around the on the placenta Respondents reported that until the placenta was delivered the life was in and that the of leaving the newborn unattended were leaving the a at delivery to care for the baby was not but early and drying it for delayed drying or in home were beliefs that drying and should occur only after bathing or after the is the is not the baby be and year is usually after the placenta is delivered for that the into the birth attendants were reported as being to the by it to the this it immediate and The respondents who reported early and drying as the key is not good for the baby to be on the for a the baby can easily if not to after year the baby with with the on to from into year recently delivered The first is usually by the birth or an and with is only in the second where the baby be year recently delivered The for using included that is not and that using is the of the first that babies are not in the water, the with the of between the baby on and the baby with and the is usually the the baby is usually and in for and to sleep is for a The for bathing after delivery include that the baby not body odour in later life, to the baby’s head, and to help the baby sleep and feel clean. The women who delayed bathing reported that they because they delivered at around they the birth and the baby for the The baby is not bathed in the because during that time the be year or because they were from the hospital were to do that during care to the baby from year Respondents reported that there would be a of to changing bathing behaviours be as the is to change may a of year especially as early bathing is in facilities in babies are bathed immediately after delivery do to the to the year The importance of keeping newborns warm and was recognized in all groups and it was reported that newborns are for at the first week of life and that the should be to the as much as Most newborns during the were The babies who were to be were as it was that the needed to care was during the first 24 it was to help the baby sleep has that but it to baby warm but to help it sleep year The qualitative data suggest that immediately after birth there is little for skin-to-skin contact because of after birth activities such as the and bathing the baby. During the mother if is not activities such as bathing, and activities the mother and baby usually on the and babies sleep on the same but the only time they close is for The concept of skin-to-skin was easily understood by the respondents and most women said they would try it if it was good for the baby. interventions to newborn mortality are being in and are key for reducing neonatal mortality (Darmstadt et al. 2005). interventions should be based on an understanding of current behaviours and beliefs (Neonatal Mortality Formative Research Working Group 2008; Parlato et al. paper provides information from rural Ghana about thermal care beliefs and the of the baby in the first weeks of life thermal care practices were not by families in the study area. A significant of newborns delivered at home and facilities had delayed were placed to and most were bathed after birth – usually with for early bathing and delayed drying/wrapping were in Ghana and Asia and included early bathing to ensure the baby is odour and et al. 2008; Kesterton Osrin et al. 2002; Iyengar et al. 2008; Khadduri et al. 2008; Darmstadt et al. The data from this study were to inform the design of the intervention which includes home in and in the first week after delivery to families on essential newborn care (Hill et al. 2008). the baby in the first week of life was this was not selected as a focus it is important not to families with birth attendants are for immediate newborn care, they were included in the intervention through and by who in in the home were to an during delivery to and the baby as the birth would be on the placenta. The intervention messages the that the of the newborn is essential for the baby’s At the time of the about 50% of women delivered in facilities. The quantitative data that facility practices were and a health facility was thus to determine what activities were required in facilities to ensure consistent behaviour change messages and to practices (Howe LD, Manu A, Tawiah-Agyemang C, Kirkwood BR, Hill Z, submitted). The study suggests that early bathing may be a behaviour to as it is to have multiple and is a This is to from et al. 2008). interventions in Asia have bathing practices (Kumar et al. 2008; Baqui et al. despite barriers. behaviour change may time and interventions should for an appropriate of time and should not be as if behaviour change is not The intervention includes a delayed bathing but also suggests a behaviour if the is not to delayed bathing – bathing with warm water, the baby for a time as and immediate drying and after information is important for behaviour change (Neonatal Mortality Formative Research Working Group respondents reported early bathing in facilities as a for community behaviour change. thus included facility activities to facility practices and ensure that and practices in the facilities the community intervention. that delayed bathing should for in babies randomized to delayed bathing had later which was to (Bergström et al. 2005). In rural the concept of skin-to-skin care was easily and women said they would be to try the of skin-to-skin care have been found in where an intervention that included care resulted in nearly all the behaviour (Darmstadt et al. a trial in Bangladesh had difficulty community at scale with only of women skin-to-skin care for the recommended time – no mortality impact was found et al. 2008). In the study skin-to-skin care was a and all the barriers in the interviews and focus groups were all Methods such as trials of practices & may be a more appropriate of understanding this behaviour in This study to the limited data on newborn care in there are that to be the The were months for the birth narratives and a of 15 days for the quantitative but respondents may not have what to the baby after they may also have difficulty the time between birth and the behaviours. More research is needed on to about newborn care practices newborn 2008). interventions to newborn mortality are being thermal care is a key component of such The design of interventions should be based on an understanding of current behaviours and beliefs. Formative research can help select which behaviours community interventions should focus who to include in the and what messages and approaches are needed to overcome behaviour change barriers. The study is by the through by the & through the of the and all of who in the formative research and all the of the intervention and also Research for their help and during data and and for their