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Abstract
Objectives To understand family and parent perspectives on newborn care provided at home to infants in the first 28 days of life, in order to inform behavioural interventions for improving care in low-income countries, where the majority of newborn deaths occur.
Design A comprehensive, qualitative systematic review was conducted. MEDLINE/PubMed, Embase and Cumulative Index of Nursing and Allied Health databases were systematically searched for studies examining the views of parents and family members on newborn care at home. The search period included all studies published from 2006 to 2017. Studies using qualitative approaches or mixed-methods studies with substantial use of qualitative techniques in both the methods and analysis sections were included. Studies meeting the inclusion criteria were extracted and evaluated using Critical Appraisal Skills Programme guidelines. Following the initial selection and appraisal, barriers and facilitators to recommended care practices across several domains were synthesised.
Results Of 411 results retrieved, 37 met both inclusion and quality appraisal criteria for methodology and reporting. Geographical representation largely reflected that of newborn health outcomes globally, with the majority of studies conducted in the region of Sub-Saharan Africa and South Asia. Specific barriers and facilitators were identified among a range of domains including: cord care, drying and wrapping, thermal control, skin to skin contact, hygiene, breast feeding, care-seeking for illness, and low birthweight recognition. Cross cutting facilitators, common to all domains were evident and included
delivery at a health facility, inclusion of female relatives in care counselling, lower healthcare costs, and exposure to newborn care behaviour change messaging in the community.
Conclusions When designing behavioural interventions to address newborn mortality at scale, policy-makers and practitioners must include barriers and facilitators important to families in low-income settings.
PROSPERO registration number CRD42016035674.
- infant, newborn
- postnatal care
- qualitative research
- care seeking
- Cambodia
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Strengths and limitations of this study
Strengths of the review include having had a librarian/information scientist in the research team, and multiple reviewers experienced in qualitative research in low-income countries, primary qualitative data collection and analysis.
Other strengths of the study was the comprehensive search strategy covering multiple relevant databases; appraisal of quality among included studies based on critical appraisal skills guidelines; and a comprehensive description of study findings.
Limitations included the exclusion of documents not available in English, and those that may have been relevant, but were outside the defined date limitations. A further limitation is that because findings are presented in the aggregate, care practices from different geographical areas may require different interventions.
Introduction
Approximately 46% of all under-five deaths in 2016 occurred during the neonatal period, the initial 28 days following birth (global incidence). Southern Asia and sub-Saharan Africa account for nearly 80% of the newborn deaths. By 2030, the Sustainable Development Goals (SDG) target is to reduce neonatal mortality to at least as low as 12 deaths per 1000 live births. However, per current trends, over 50 countries will fail to meet this target on newborn survival.1 Yet, the majority of these deaths are preventable.2
During the neonatal period, care provided by parents and caregivers is critical for newborn survival.3 Optimal or essential newborn care practices as defined by the WHO include immediate drying and wrapping of newborns after birth, initiating skin-to-skin (STS) contact, clean cord care, dry cord care, immediate initiation of breast feeding and exclusive breast feeding until 6 months of age, as well as ensuring warmth (thermal control) of the newborn through delayed bathing.4 In addition, parents or caregivers at home must also provide nurturing care, safety and security, and responsiveness to the newborn’s needs. The provision of quality, effective care at the home and community level is critical for improving newborn health outcomes and promoting optimal early childhood development. A reduction in neonatal mortality by 25% can be achieved by scaling up community interventions, including provision of optimal home care.5 Although feasible interventions exist to reduce newborn mortality, uptake of these interventions is low.6
In order to increase scale-up of coverage and implementation of effective home and community-based newborn care practices, providing data on research priorities for newborn health is key.7 Researchers have identified specific domains related to caregiver perceptions and behaviours as priorities.8 Qualitative research has been particularly useful for obtaining information on newborn care practices at home, which often vary based on the sociocultural context in low-income countries.9
Despite the existence of multiple individual qualitative and formative research studies on home and community-based newborn care, a systematic review of the available qualitative research is lacking. Therefore, we conducted a systematic review to provide data to improve both programming and policy for home and community care for newborns.7
The primary objective of this study was to systematically review qualitative literature to understand parent and family experiences with home newborn care practice in low-income countries, presenting information related to barriers and facilitators to inform behavioural interventions focused on improving newborn survival and care.
Methods
The review followed guidelines from the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement.10 Due to the emphasis on qualitative research, the review primarily employed the ENTREQ guidelines for reporting, while also drawing guidance from Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) which is more specific to the requirements of quantitative literature reviews.10 11
Newborn care practices were defined as all actions taken by parents/caregivers that provide for the essential biological, physiological and psychological needs of the newborn infant following delivery and up to the end of the newborn period (28 days of life). These included, but were not limited to, the essential newborn care practices as defined by WHO: cord care, drying and wrapping after delivery, initiation of breast feeding, bathing, thermal control, breast feeding and care-seeking for newborn illness.12
Four of five researchers involved in conducting the review, analysing the results, and writing up the manuscript had strong experience in qualitative research methods, and hold graduate and/or doctoral level qualification in public health, with a specialisation in research methods (ANB, EFK, AK and SE). One researcher (RH) is an information scientist with a qualification in library sciences and specialisation in support to research in science and biomedicine.
Patient and public involvement
No patients and or public were involved in this systematic review.
Inclusion and exclusion criteria
Studies were included if they used qualitative data collection methods such as interviews, focus groups, direct observation and participatory action research. Inclusion requirements also stipulated that studies needed to have a well-described methodology section and a clear description of the qualitative data analysis methods and process (eg, grounded theory, narrative analysis, content analysis, thematic analysis). Finally, data on newborn care at home must have been directly obtained from parents or caregivers of newborns (infants under 28 days of age, including low birth weight or small babies), whether born at home or at a facility, with or without skilled attendance, and regardless of whether the study also included additional data from non-family members or health workers such as traditional birth attendants (TBAs) (which data were not used for this review). Caregivers were defined as mothers/fathers or other adult family or community members who provided day-to-day physical and psychological support to meet the basic needs of newborn infants. Data gathered from community health workers, and from professional or non-professional healthcare providers, were not used or included in this study although it may have been present in one of the articles included in the review.
Excluded studies were those for which it was difficult to extract qualitative data (eg, mixed methods studies without clearly labelled data, or studies in settings where perceptions of parents’/caregivers’ experiences of newborn care practices could not be clearly identified, such as summaries or aggregate data). Commentaries, protocols and systematic reviews were not included in the analysis. Additionally, studies from countries other than those defined by the World Bank as low-income countries and lower-middle-income countries (which have a gross national income per capita of less than $4125) were excluded.13
Search strategy
The review began in 2016 and initially targeted literature published in the previous ten years. Due to delays in the publication process, however, we extended a further year to encompass the timeframe 2006–2017. The following electronic databases were searched: MEDLINE (PubMed), Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL: EBSCOhost). A health sciences librarian (RH) developed the database searching strategy and conducted the final searches. The initial search strategy was developed for MEDLINE and then adapted for other databases. Medical Subject Headings (MeSH) were used followed by free-text terms using controlled vocabulary (see the online supplementary appendix for a detailed description of the search strategy). Only articles in English were included due to potential difficulties in translating and interpreting foreign language qualitative data by native English-speaking reviewers, and to ensure that the review covered the most current literature on infant and young child feeding practices.
Supplemental material
Figure 1 presents the selection process which followed the PRISMA guidelines for reporting of systematic reviews.11 Search results were initially imported into Endnote reference management software (Thomson Reuters [Scientific]) and duplicates and irrelevant studies were removed. Four independent reviewers screened study titles and abstracts for suitability against inclusion and exclusion criteria. The decision to include or exclude a study required agreement of two reviewers. If after consultation a decision was not reached, a third reviewer made the final decision.
Selection flow chart of review process.
Data extraction
For organisation of extracted data, a unified matrix was used to record specific characteristics of included studies. Extracted data included reference details (author/data/publication), methodological approach (eg, interviews/focus groups), conceptual framework (eg, grounded theory), objectives or aims of the study, sampling methodology, sociodemographic characteristics of participants, country/region and analysis method(s). The results of the selection process and data extraction, with selected characteristics, are presented in table 1.
Characteristics of included studies*
Quality appraisal
After all articles were selected for review inclusion, each article was assessed and scored by two reviewers (AB, EFK) according to the Critical Appraisal Skills Programme (CASP) checklist14 to describe quality and internal validity. All the selected studies met at least half of criteria defined by the CASP checklist (see 1–10 below) including domains such as appropriateness of study design, data collection techniques and analysis methods. The detailed CASP criteria are as follows:
Was there a clear statement of the aims of the research?
Is a qualitative methodology appropriate?
Was the research design appropriate to address the aims of the research?
Was the recruitment strategy appropriate to the aims of the research?
Was the data collected in a way that addressed the research issue?
Has the relationship between researcher and participants been adequately considered?
Have ethical issues been taken into consideration?
Was the data analysis sufficiently rigorous?
Is there a clear statement of findings?
How valuable is the research?
Possible responses: yes, no and cannot assess due to missing information.
For each checklist item, studies were scored with a 1 if a CASP criterion was met and 0 if not. These scores are available in table 2.
Critical Appraisal Skills Programme (CASP) Assessment
Following data extraction, relevant text from the results, discussion and conclusion sections, which provided information directly pertinent to home care of newborns from the perspectives of family caregivers, were imported into NVivo V.11 qualitative software (NVivo qualitative data analysis software; QSR International, 2015).
Following the appraisal, deductive content analysis based on the WHO guidelines15 was employed to identify domains for investigation and presentation within a framework analysis approach.16 The focus of analysis was on manifest content rather than latent content.17 For each domain of newborn care, study findings were extracted and information on barriers and facilitators synthesised. Then, a narrative summary of the identified domains and themes, developed according to content, was reviewed by the research team (SE, ANB, EFK) to produce a consensus-based listing including barriers and facilitators to recommended newborn care practices.
Results
Geographical overview of studies reviewed
The vast majority of studies identified emerged from research carried out in the Sub-Saharan region, while the South Asian region was also well represented in the qualitative literature relating to newborn care practices at home.
Sub-Saharan Africa
Studies from the African region comprised 24 of 37 included for review, and information presented in the studies described the full range of home based newborn care practices.
South Asia
From the South Asian region, 8 of 37 studies presented information on newborn care practices, covering more general rather than specific domains of newborn care, though one focused on breast feeding.
Southeast Asia
Three studies, two related to breast feeding in Cambodia and Lao PDR, along with another from Cambodia related to skin care, were identified from the Southeast Asian region.
Latin America/Caribbean
Two qualitative studies were identified from the Latin America/Caribbean region, from Guatemala and Haiti, related to breast feeding and cord care respectively.
Barriers and facilitators
A comprehensive list of barriers and facilitators stratified by the recommended care practice that were generated through the data synthesis exercise appears in table 3. Among the 37 studies in this review, many of the reported barriers and facilitators were cross-cutting for recommended newborn care practices (ie, cord care, drying and wrapping after delivery, prompt initiation of breast feeding, bathing, thermal control, breast feeding and care-seeking for newborn illness). Across all practices, delivering at a health facility, including grandmothers in decision-making processes during and after pregnancy, low healthcare costs, and exposure to newborn care messaging in the community were reported as important facilitators for adoption of recommended newborn care practices. Common barriers across the recommended practices included traditional and historical beliefs and practices, cultural and gender norms, geographical location, conflicting health messaging and societal pressures.
Barriers and facilitators described in articles reviewed
Barriers that influenced adoption of recommended cord care practices included lack of resources (eg, clean water and razor blades), misinformation on timeliness of cord cutting, religious and cultural beliefs, and untrained birth attendants. Facilitators included institutional delivery, exposure to educational campaigns on safe and hygienic cord cutting practices, community outreach activities promoting hand-washing and provision of clean razor blades, decision-making by grandmothers and women leaders, and cord-care counselling by TBA.
Barriers to timely drying and wrapping included perceptions of newborn vulnerability and dirtiness, conflicting advice from household stakeholders, and waiting for delivery of the placenta. Facilitators included institutional delivery, exposure to behaviour change campaigns on newborn thermal regulation, traditional wrapping practices, and the presence of more than one birth attendant during delivery.
Factors impeding delayed bathing included societal pressure for cleanliness, preference for immediate bathing due to concerns about ritual pollution and hypothermia, negative perceptions of the vernix and immediate bathing at health facilities. Factors that facilitated delayed bathing after delivery included hospital-based birth, exposure to newborn care messaging on the radio during pregnancy, communication between healthcare workers in the community and at the facility during pregnancy, and social support from other women in the household.
Factors inhibiting STS care and thermal control practices included use of blankets instead of STS contact, not immediately releasing baby to mother following delivery, early bathing, concerns of disease transmission, and maternal household duties. Facilitators included exposure to kangaroo care messaging during pregnancy, observing positive newborn health outcomes of other mothers who used kangaroo care practices, medical advice from healthcare providers, and prior participation in behaviour change interventions.
Barriers to care-seeking for illness included lack of transport, minimal financial resources, distances to health facility, gender norms, prior negative experiences at health facilities, and cultural norms such as protective isolation during the postpartum period. Facilitators included family knowledge and recognition of danger signs and illness symptoms, lower healthcare costs, community education and support from religious leaders, and exposure to newborn health campaigns.
Barriers to initiating breast feeding included spatial/physical seaparation, conflicting health messages, mother exhaustion, baby not crying for milk, historical and traditional beliefs to discard colostrum, and education. Facilitating factors included community and family member knowledge, information provided during health facility-based birth, attendance by trained TBAs, being a first time mother, and exposure to breast feeding education and policy campaigns.
Discussion
Effective interventions to improve newborn survival require information on a number of complex factors related to essential newborn care.18 In addition to collecting improved quantitative data for neonatal survival, qualitative data are essential for behavioural interventions targeted to specific populations.19 Few qualitative systematic reviews exist to synthesise information from perspectives of parents on newborn care. One review from 2014 focused on STS contact and included 29 studies containing data from nine countries.20 Findings from that review centred on the experience of becoming a parent under unfamiliar circumstances, and thoughtfully considered the experiences of parents in the unique practice of STS care. The authors did not restrict the review to low-income settings, though studies from Uganda, Brazil and South Africa were included. Our findings add further information to the peer reviewed literature from low-income countries, where the majority of newborn deaths occur.
Another review was recently conducted in relation to thermal care for newborns in Sub-Saharan Africa.21 The review focused on sociocultural factors and identified a number of potentially harmful cultural norms and traditions which influence care across African settings. Similar to what has been found in the present review, that review identified caregiver factors and contextual barriers as well as facilitating factors, but in contrast to this review these were specific to thermal control, which may not represent the full range perspectives for other newborn care practices. In addition, that review’s restriction to Sub-Saharan Africa settings limits the potential for transferability of the findings to other geographical settings, and data from parents or family caregivers was not the focus.
A systematic review covering neonatal care practices in Sub-Saharan Africa was recently undertaken.22 The authors of that review included both quantitative data and qualitative data published from 2001 to 2014, whereas our review focused on qualitative data only, and covered the period 2006–2017, though similar findings were identified in both reviews in relation to care practices, confirming the findings. Bee et al also included studies of facility-based and home-based care (unlike our study which focused on data from parents regarding home care) and noted the limitation of data having come mainly from five countries, highlighting a need for research from a wider geographical area, such as has been provided in the present review. Given that birth at home presents unique risks to the newborn,23 information from these settings is key. Whereas the present review focused on barriers and facilitators identified through qualitative research, the review by Bee et al centred on the prevalence of key immediate newborn care practices, however, the findings of both reviews are concordant.22
Policy recommendations and current approaches to reducing newborn mortality have not yet been appropriately scaled to reduce newborn mortality to levels targeted by the SDGs.24 In the context of international calls for reduction of newborn mortality and stillbirths,25 it will be essential for interventions to meet the needs of families and parents caring for newborns. This systematic review of qualitative research, drawn from the literature across low-income countries, is an important step to providing data on the range of newborn care practices at home, which is specifically relevant to behaviour change in settings where high newborn mortality continues.
Conclusions
This systematic review identified qualitative studies reporting on the experiences and first-hand accounts of family members and caregivers in low-income countries who are responsible for providing essential newborn care for their infants up to the first 28 days of life. The review identified barriers and facilitators commonly reported in studies of newborn care practices. The findings presented here are directly applicable to social and behavioural change initiatives aimed at improving care practices for better newborn health outcomes in low resource settings.
References
Footnotes
Contributors Conception and design of the work: ANB, RH. Data collection: ANB, AK, EFK, RH. Data analysis and interpretation: ANB, AK, EFK. Drafting the article: ANB, AK, EFK, SE, RH. Critical revision of the article: ANB, AK, EFK, SE, RH. Final approval of the version to be published: ANB, AK, EFK, SE, RH.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement All data came from published articles available from electronic databases which are openly accessible.
Patient consent for publication Not required.