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Essential newborn care practices in Zambia

Neonatal mortality remains high in Zambia and is declining slower than infant and under five mortality. Improved adoption of essential newborn care (ENC) could help mitigate this situation. To determine the adoption of ENC practices in Zambia, cross-sectional data was used to assess ENC practices including baby kept warm, umbilical cord care and breastfeeding. Chi-square was used to assess whether maternal and social demographic factors were related to ENC. Households surveyed were 12,507, which included 5,741 women with children under two years. Findings show that 95.4% of babies were dried immediately after birth, 96.5% wrapped in a cloth/blanket, 76.7% put on mother’s torso and 68.5% head covered (51.6% for all four). Eightyfive- point six percent of baby’s cords were cut with a sharp and clean instrument, 46% cord kept dry and 42.1% cord kept clean (31.2% for all three). Ninety-six-point nine percent of babies were breastfed, 89.3% were initiated within one hour and 93% exclusively breastfed for the first 3 days post-delivery (82% for all three). Babies kept warm were associated with skilled birth attendance (SBA) and province, umbilical cord care with SBA, >4 antenatal care (ANC) visits, marital status and province, and breastfeeding with >4 ANC visits, marital status and province. Early and exclusive breastfeeding is widely practiced. However, appropriate thermal and cord care practices are low. There is need for a scale-up of appropriate newborn care practices in Zambia and SBA could play an important role in this regard.


Introduction
Globally neonatal deaths have declined by more than half from 5 million in 1990 to 2.4 million in 2019, with the majority occurring in developing countries. 1 In Zambia, neonatal mortality has followed a similar decline as observed globally, dropping from 43/1000 live births in 1992 to 27/1000 live births in 2018. 2 However, over the same period, the drop in neonatal mortality lagged behind the declines in under five mortality (from 191 to 61/1000 live births) and infant mortality (107 to 42/1000 live births). 2 The sluggish decline in neonatal mortality necessitates the need for intensified focused interventions so as to fast track improvements in newborn health.
The major causes of neonatal deaths include prematurity, infections, asphyxia and intrapartum causes. 3 The majority of newborn deaths occur in the first week of life, and thus essential newborn interventions implemented in this period could have a significant positive impact. If appropriate interventions are adopted, preterm, intrapartum and neonatal deaths due to infections could be reduced by more than half in a cost-effective manner. 4 Studies show that essential newborn care (ENC) practices are effective in reducing neonatal mortality rates. 5,6 ENC interventions do not only enhance newborn survival but also enable them to thrive. 7 The Zambia Ministry of Community Development, Mother and Child Health developed guidelines in 2014, which guide ENC provision. These guidelines prioritise basic ENC interventions such as prevention of infection, keeping the baby warm, appropriate umbilical cord care and early and exclusive breastfeeding, which can play a pivotal role in improving newborn health outcomes.
It is not clear the extent to which essential newborn practices have been adopted in Zambia as they are not captured in routine monitoring tools nor in the Demographic and Health Surveys (DHS) that are done every five years. This paper provides data on ENC practices, namely umbilical cord care, keeping the baby warm and early and exclusive breastfeeding in rural Zambia and socio and demographic factors associated with the practices. The findings could be used to influence planning and shape priority interventions to improve ENC in Zambia.

Ethical considerations
Ethical clearance for the multi-sectoral end of program evaluation was obtained from the Zambia ERES Converge Ethics Committee (reference number 2021-April-008).
Informed consent was obtained from respondents, and confidentiality was main-Contributions: SM led the overall design, data analysis and developed the draft and final version of the manuscript; MI, TC, CC contributed to development of the study and reviewed and provided input to the final manuscript. All authors agreed to the final version of the manuscript submitted.
Conflict of interest: The authors declare no conflict of interest.
Availability of data and materials: All data generated or analyzed during this study are included in this published article.
Ethics approval and consent to participate: Ethical clearance for the multi-sectoral end of program evaluation was obtained from the Zambia ERES Converge Ethics Committee (reference number 2021-April-008). Informed consent was obtained from respondents, and confidentiality was maintained throughout the evaluation. Personal identifiers such as names were removed, and the data stored safely with only authorized persons allowed access to it.
Informed consent: The manuscript does not contain any individual person's data in any form.
tained throughout the evaluation. Personal identifiers such as names were removed and the data stored safely with only authorised persons allowed access to it.

Study design
The study used a cross-sectional design to evaluate a multi-sectoral end of program evaluation in Zambia.

Study setting
The study used data collected for an evaluation of 28 Area Programs (APs) implemented by World Vision Zambia between 2016 and 2021 and which are predominantly in rural areas.

Data sources and target population
Data collection was done by the University of Zambia, Institute of Economic and Social Research who were contracted by World Vision Zambia. The collection of data was done between April and June, 2021, using World Visions Caregiver Survey questionnaire for program evaluations first published in 2013 8 and revised in 2020 with adaptations made to suit the Zambia context. Data was collected using mobile phones, cleaned and then uploaded into the server.
The broad target population of the evaluation consisted of parents/caregivers of children aged 3-6 years, mothers or caregivers of children under five years and women aged 18 to 49 years and pregnant women. The specific target population for this study was mothers of children aged 0-23 months.
Information on ANC, delivery and ENC was based on the mother's reports.

Sampling technique and sample size
The sample size was calculated using the World Vision sample size calculator available in the Baseline Field Guide. 9 The sample size was calculated with the statistical power to detect change set at 0.84, a design effect of 2, with the default probability of committing a Type-1 error set at 1.96. The minimum sample size required in order to detect statistically significant differences between proportions between 2 survey domains at AP level was 358 giving a total of 11,098 for all the 31 APs.
A two-stage cluster sampling was used to select sample households to be interviewed. All the APs and their respective zones were included within the sample. The first stage of sampling entailed random selection of villages from zones; however, Probability Proportion to Size (PPS) Zones was used to ensure larger villages and zones contributed more households compared to smaller ones. The zones included were selected by first listing all zones alphabetically and then using systematic random sampling to choose the ones to be included. In the second stage, households were selected using the random walk method starting from the centre of the village.

Data analysis
Cleaned data in the server was exported to SPSS version 25, which was used for the analysis.
The ENC characteristics of interest included 1. Baby kept warm, which had four sub-components (i) whether the baby was dried immediately after birth (ii) baby wrapped in a warm cloth or blanket (iii) baby put skin to skin on mother's torso and (iv) baby's head covered. 2. Umbilical cord care, which had three sub-components (i) umbilical cord cut with a sharp and clean instrument, (ii) umbilical cord kept dry and (iii) umbilical cord kept clean. 3. Breastfeeding, which consisted of three components (i) breastfed at all (ii) breastfed within the first hour and (iii) breastfed within the first three days.
These ENC practices were compared across social and demographic strata to see if there were any differences. Weighting was done during the analysis to adjust for the uniform sample sizes used at the AP level as opposed to proportions based on population size.

Results
The total number of households surveyed was 12,507 of which the majority were from Southern (28.7%) province where most programs were located and the least (3.5%) in Western, which has the least number of programs. In terms of marital status, most household heads were married (82.2%), 4.4% were single, 5.9% widows/widowers, 6.8% divorced or separated and 0.7% cohabiting (Table 1).

Pregnancy and Delivery
The survey questions on ENC were asked to mothers with children under two years, who were a total of 5,741. The vast majority (85%) of the mothers with children under two years had four or more ANC visits and 92.3% were delivered by a SBA (SBA was defined as a mother delivered by either a doctor, midwife, nurse or a clinical officer). There were 94.7% who delivered in a health facility with the rest (5.3%) delivering at home.

Newborn care
The newborn care results are broken down by the three essential practices assessed, namely, if the baby was kept warm, cord care and early and exclusive breastfeeding for the first three days.

Baby kept warm
Ninety-five point four percent of babies were dried immediately after birth and 96.5% wrapped in a warm cloth or blanket however, only 76.7% were put skin to skin on the mother's torso and only 68.6% of the babies had their heads covered. Only 51.6% of babies had all four components of keeping the baby warm which included dried immediately after birth, wrapped in a warm blanket or cloth, put skin to skin on mother and head covered.
Children who were born at home (44%) were less likely compared to those delivered in a health facility (52%) to receive all the four components of keeping the baby warm and the difference was statistically significant (p=0.008). A similar significant difference (p=0.001) is seen with SBA (52.2%) versus non-SBA (44.3%). Babies whose mothers had four or more ANC visits (51.6%) performed slightly worse than those with less than four or more ANC visits (54.7%), but this was not statistically significant (p=0.106).
The percentage of babies who received all the four components of being kept warm varies considerably by province from 34.3% in Eastern to 81% in Western and the differences were statistically significant (p<0.001). In relation to household head, those households whose education status was classified as tertiary or other (54.1%) performed best while those where the respondent didn't know the educational status of household head faired worst and the differences were significant (p<0.001). Those where the household head was divorced/separated (46.2%) and widowed/widower (48.4%) fared worse than their counterparts who were single (50.6%), married (52.3%), and cohabiting (51.1%) but the differences were not statistically significant (Table 2).

Cord care
The study found that 85.6% of babies were reported to have had their umbilical cord cut with a sharp and clean instrument. However, only 46% of them had their cord kept dry and 42.1% had their cords kept clean. Only 31.2% of babies were reported to have received all the three components of cord care (cord cut with a sharp and clean instrument, kept dry and clean).
Similar to babies kept warm, those who were delivered in a health facility were more likely to receive the three components of cord care (31.6%) compared to those who were delivered at home (23.8%) and this was significant (p=0.004). In babies whose delivery was assisted by a skilled attendant, all three components of cord care were received by 31.9% compared to 23% for those who were delivered by non-SBAs and the difference was significant (p<0.001). There was also a significant difference (p<0.001) in babies receiving all the three components of cord care in mothers who had four or more ANC visits 32.6% compared to those whose mothers had less than four ANC visits (23.8%).
Eastern province with 21.3%, performed the worst while Western performed the best with 48.6% and differences among provinces were found to be significant (p<0.001). Babies whose household head education status was tertiary or other performed worst (29.2%) and those who did not know the household head education status (34%) performed best.

Breastfeeding
The study found that 96.7% of babies were breastfed, 89.3% breastfed within one hour of birth and 93% exclusively breastfed for the first three days with 82% having all the three components of breastfeeding.
Mothers who had four or more ANC visits (84.4%) were more likely to have all the three components of breastfeeding compared to those who had less than four ANC visits (70.7%) and this was significant (p<0.001). There was no significant difference (p=0.574) in breastfeeding in mothers who were delivered in a health facility (82.1%) compared to those who delivered at home (80.8%). Similarly, mothers who delivered with a SBA (82.3%) performed only slightly better than those who were delivered by a non-SBA (79%) but this was not significant (p=0.097). In terms of provinces Lusaka (88.9%) performed best while Central (75.8%) performed worst in having the three components of breastfeeding and the differences among provinces was again significant (p<0.001). Households where the head was cohabiting (65.8%) performed worse than those where the household head was single (79.5%), married (81.8%), divorced/separated (84.7%) and widower/widows (87.8%) and this was significant (p=0.004). Babies from households where the heads had tertiary or other education status (75.8%) performed worse than those whose household heads had no education (85.1%), didn't know the education status of the household head (78%), primary education (83.5%), and secondary (79.9%) ( Table 4).

Baby kept warm
The study found that nearly all babies are dried immediately after birth and wrapped in warm cloth or blanket but only just over three quarters were put skin to skin on mother's torso and just over two thirds their heads were covered. It is of concern that only a half of babies receive the four components of keeping the baby warm, which is one of the essential components of newborn care. This means that half of all babies are not adequately kept warm after birth which predisposes them to hypothermia which can lead to death.
The practice of all the four components of keeping the baby warm was associated with delivery in a health facility and SBA. These two are closely related as the vast majority of babies who are delivered in a health facility are by a skilled worker. However, attendance of four or more ANC visits did not have a significant relationship with having all four components of keeping the baby warm. This is likely because the practices of keeping the baby warm are done mostly by the birth attendant and so if she/he is not skilled may not follow the recommended post-delivery thermal care practices.

Cord care
Good umbilical cord care is essential for preventing infections which are one of the leading causes of neonatal deaths. 3 The study found that most babies have their cords cut by a clean and sharp instrument however, less than half keep the cords dry or clean. In addition, less than a third of babies received all the three components of umbilical cord care assessed. This poses a risk of infection through the umbilical cord, which is an important entry site for infections in newborns. 10 The umbilical cords may not be kept clean and dry because culturally, some mothers apply substances to the cord. A study in Southern Zambia found that the common substances applied include cooking oil, baby lotion, breast milk, root powders, burnt gourds and ash. 11 The findings show that mothers who receive four or more ANC visits compared to those with less than four ANC visits, deliver in a health facility compared to those who deliver at home or have a skilled delivery compared to non-skilled delivery are more likely to have all three components of all the elements of umbilical cord care assessed. These results support the need for mothers to attend four or more ANC visits and to deliver in health facility by SBA. During ANC and also post-delivery in health facilities, mothers are taught how to care for the cord which helps foster appropriate cord care practices when they go home.

Breastfeeding
Breastfeeding, in particular colostrum, is important because it provides antibodies that protect children against infections and also enhances child survival when initiated early. [12][13][14] This study found that breastfeeding is almost universally practiced (97%), with the vast majority of babies breastfed exclusively for the first three days (93%) and most starting within the first hour after birth (89%). However, only just over fourfifths of babies received all the three components of breastfeeding. ANC (four or more visits) was found to be an important factor contributing to having all the three components of breastfeeding. However, delivery in a health facility or skilled birth attendance did not have a significant effect.
We did not find comparable studies in Zambia that evaluated the components of ENC, but our findings are similar to Multiple Indicator Survey studies done in Zimbabwe and Lesotho 15,16 which capture some of the indicators. These studies show that the practice of drying the baby immediately after birth is high but that of skin-toskin contact is less so and appropriate cord care practice is generally low. One study in Zambia found that although there was good knowledge of ENC in general, young mothers had low knowledge of umbilical cord care. 17 In Ghana, essential thermal care practices were found to be associated with ANC and education status, cord care and good neonatal feeding with ANC 18 while in Ethiopia ENC was correlated with ANC and urban residence but not with marital and educational status, religion and ethnicity. 19 In Bangladesh, ANC, SBA, birth order and mothers age were found to influence ENC practices considerably 6 while in Uganda, place of delivery and socioeconomic status did not have a correlation with ENC. 20 The definitions of ENC varies consider- ably across studies which makes it difficult to cross compare. We thus recommend for the standardization of indicators of ENC to make it easier for comparison across countries. Multiple studies show that higher education status tends to be associated with better maternal and child health-seeking behavior and outcomes [21][22][23] but in this study, household head educational status was only correlated with the three components of keeping the baby warm but not with the three components of umbilical cord care nor the three components of breastfeeding. The reason for this difference is not apparent, but it may be because the drivers of each behavior are different and the influence of education status on each may be different. It could also be related to the fact that in this study education status was measured using household head as opposed to mother's education which is used in most other studies.

Limitations
The evaluation questionnaire length was reduced so as to shorten the time spent by enumerators at household so as to reduce the risk of spread of COVID-19. As a result, some demographic data such as age of mother, education status, religion etc. were not collected which limited the scope of factors explored by the study. The study population was mostly rural and thus limits the generalizability of the findings.

Conclusions
Although the country has guidelines for the implementation of ENC, the study found that the adoption of these practices is still relatively low in Zambia. Breastfeeding is well adopted. However, thermal care and umbilical cord care still lags far behind.
ANC and skilled birth attendance are important factors that can help increase coverage of ENC practices in the country.
Given the sluggish decline in newborn deaths compared to infant and under-five deaths, there is a need for the government to prioritise newborn interventions which could go a long way in reducing neonatal mortality. In addition, there is limited information on newborn care practices and thus it is recommended that future national surveys such as the Zambia DHS should consider including the newborn care practices evaluated in this study. There is need for studies to explore the factors that contributed to the relatively low prevalence of some of the essential newborn care practices in Zambia.